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Prevention and Treatment of Venous Thromboembolism in Patients with IBD

April 25, 2014 8:37 PM

Guidelines for the management of venous thromboembolism (VTE) from the American College of Chest Physicians do not address patients with inflammatory bowel disease (IBD), a group with a high risk of both VTE and gastrointestinal bleeding. The current published consensus statements identify how the 9th  American College of Chest Physician (ACCP) guidelines on antithrombotic therapy and prevention of thrombosis should be applied to patients with IBD, and how patients with IBD should be managed when those guidelines are not appropriate or have not addressed issues that are specific to IBD patients.                                                                                                                                                                                                 
In Summary
  • Inflammatory Bowel Disease (IBD) patients have about a 3-fold higher risk of Venous Thromboembolism (VTE) compared with the general population.
  • Moderate to severe disease activity drives the increased risk of VTE in IBD and should be considered a provoking factor.
  • For the prevention of VTE, strong recommendations are made for 1) anticoagulant thromboprophylaxis over no prophylaxis for patients with IBD who are hospitalized with moderate to severe IBD flares without severe bleeding, for 2) anticoagulant thromboprophylaxis over no prophylaxis for inpatients with IBD who have undergone major abdominal-pelvic or general surgery, and 3) against anticoagulant thromboprophylaxis in outpatients with an IBD flare if they have not had a previous VTE.
  • For the treatment of VTE, strong recommendations are made for a minimum of 3 months of anticoagulant therapy for adult and pediatric IBD patients with a symptomatic DVT, PE, or splanchnic vein thrombosis. If anticoagulant therapy is being stopped in patients with a reversible provoking factor, it should not be stopped until the risk factor has resolved for at least 1 month.

  • Hospitalized patients with moderate-to-severe flares (without severe bleeding) should receive anticoagulant thromboprophylaxis with low-molecular-weight heparin, heparin, or fondaparinux.

  • Patients hospitalized for indications unrelated to IBD or for IBD with non-severe gastrointestinal bleeding should receive anticoagulant prophylaxis.

  • Hospitalized patients with severe IBD-related bleeding should receive mechanical prophylaxis (preferably intermittent pneumatic compression (IPC)). Once IBD-related bleeding is no longer severe, substitute anticoagulation for mechanical prophylaxis.

  • Patients should receive anticoagulant prophylaxis during hospitalization for major abdominopelvic or general surgery.

  • Outpatients with IBD flares and no prior VTE do not need prophylaxis.

  • Patients with prior VTE and moderate-to-severe flares should receive anticoagulant prophylaxis unless prior episodes occurred only after major surgery.

  • Pregnant women with IBD should receive anticoagulant prophylaxis after C-section until hospital discharge.

  • Patients with VTE who have coexisting IBD do not need testing for hereditary or acquired hypercoagulable states.

  • Patients who experience their first episode of VTE while in remission should receive indefinite anticoagulation unless there is an unrelated reversible provoking factor (then a minimum of 3 months).

  • Patients who experience their first episode of VTE in the presence of active disease should be anticoagulated until IBD is in remission for 3 months.

  • Recommendations for pediatric patients are similar to those for adults.

  • Patients with symptomatic acute splanchnic vein thrombosis (portal, mesenteric, splenic vein thrombosis) should be treated with principles similar to those with VTE in other sites.

  • Patients with asymptomatic, incidentally detected splanchnic vein thrombosis (on imaging studies) should not be anticoagulated.

Please review the original position statement as published in Gastroenterology March, 2014 by the Canadian Association of Gastroenterology.
Nguyen GC et al. Consensus statements on the risk, prevention, and treatment of venous thromboembolism in inflammatory bowel disease: Canadian Association of Gastroenterology. Gastroenterology 2014 Mar; 146:835.