Chronic Liver Disease - Venous Thromboembolism ( VTE ) Prophylaxis Guidelines for Patients with

Publication: 01/02/2015  --
Last review: 29/01/2018  
Next review: 29/01/2021  
Clinical Guideline
CURRENT 
ID: 4098 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Venous Thromboembolism (VTE) prophylaxis guidelines for patients with chronic liver disease

Summary of Guideline
Background
Diagnosis
Investigation
Treatment / Management

Summary of Guideline

A venous thromboembolism (VTE) risk reduction guideline for patients with chronic liver disease (CLD).
Produced and developed in response to a divisional clinical governance meeting request in 2013.

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Background

The basic principle underlying this guideline is that cirrhosis and decompensated liver disease represents a highly prothrombotic state. However, it is widely recognised that prolonged prothrombin time/INR and thrombocytopenia are both frequent findings in this group of patients, which might be assumed to be protective, but actually are not. These patients are at risk of variceal bleeding, and potentially of falls if encephalopathic.

Whilst thrombotic episodes occur at a higher rate in this population compared to the general population, evidence on where risk of VTE prophylaxis outweighs risk of thrombosis at varying levels of coagulopathy and thrombocytopenia, is scarce.

Platelet counts are often low in cirrhosis due to portal hypertension and "pooling" in the spleen. Platelet function may be normal, and platelet mobilisation may be possible in the event of bleeding.

The British Society of Gastroenterology (BSG) has recently developed a cirrhosis care bundle which includes VTE prophylaxis. This is not yet in published form, but was presented at the annual BSG meeting in June 2014.

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Diagnosis

N/A, as this is a preventative strategy.

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Investigation

This is a preventative strategy. A VTE risk assessment tool exists and should be used alongside this guideline. It must be completed for all inpatients. http://nww.lhp.leedsth.nhs.uk/VTE/RAtools.aspx

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Treatment / Management

These guidelines have therefore been reached by consensus by the guideline authors. Recommendations are as follows:

  1. All patients should be considered for VTE prophylaxis with Low Molecular Weight Heparin (LMWH) unless there is evidence of active bleeding. In the setting of active bleeding, the use of VTE prophylaxis may be withheld until bleeding is satisfactorily controlled.
  2. Anti-embolism stockings can be used in addition to LMWH, or without if there is a contra-indication, and details regarding assessment of patients for these can be found on detail.aspx?ID=2435
  3. We advise that using VTE prophylaxis with LMWH is safe in patients with platelet counts of 50 and higher and INR of 2.5 or lower.
  4. This does not preclude the use of VTE prophylaxis with LMWH in patients in patients with parameters outside these limits but it is reasonable to consider these patients the following day in discussion with a consultant within 24 hours of admission if admitted out of hours. The VTE risk assessment should be completed on admission, because level of mobility and additional factors should be considered in decision making.
  5. We advise these patients fall into a high risk category for VTE prophylaxis i.e the higher 4500 unit dose of tinzaparin is appropriate, unless the patient is <50kg weight or >100kg weight in which case calculate tinzaparin dose according to weight at a dose of 50 units/kilogram. The following link gives guidance on how to calculate 
  6. For patients with a creatinine clearance less than 20mLs/minute use enoxaparin 20mg od (or 40mg if weight > 100kg). Note enoxaparin dosing is based on Creatinine Clearance not eGFR. Creatinine clearance should be calculated for elderly patients (age over 75), patients with eGFR < 30mL/min/1.73m2 and for low body weight (less than 60kg). A calculator can be found on http://nww.lhp.leedsth.nhs.uk/Calculators/Renal/index.aspx)

VTE prophylaxis medication should be omitted the day prior to invasive procedures such as:

  • Angiography ( incl. Transarterial chemoembolization (TACE)
  • Endoscopic retrograde cholangiopancreatography (ERCP)
  • Transjugular liver biopsy
  • Transjugular intrahepatic portosystemic shunt (TIPSS)
  • Liver biopsy

As long as there is no sign of post-procedure bleeding, VTE prophylaxis can commence 24 hours after the procedure if the patient remains in hospital.

It is not necessary to omit VTE prophylaxis ahead of procedures such as diagnostic upper GI endoscopy, endoscopy for variceal endotherapy, diagnostic colonoscopy. Please refer to endoscopy guidelines if in doubt.

Patients with compensated chronic liver disease admitted electively for what is anticipated to be an uncomplicated procedure in the above cohort group, requiring an admission for under 48hrs can be considered exempt from VTE risk assessment. However, if they are an inpatient at 48hrs a VTE risk assessment should be completed.

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Provenance

Record: 4098
Objective:

Aims

Reduce the risk of venous thromboembolism (VTE) in patients with chronic liver disease (CLD).

Objectives

To provide evidence-based recommendations for appropriate VTE risk assessment and management of patients with CLD admitted to hospital.

Clinical condition:

Chronic liver disease (CLD)

Target patient group: Patients with compensated or decompensated chronic liver disease on any ward within LTHT
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

References and Evidence levels:

C. Expert consensus.
D. Leeds consensus. (where no n ational guidance exists or there i s wide disagreement with a level C recommendation or where national guidance documents contradict each other)

  • Tsochatzis EA, Senzolo M, Ger mani G, Gatt A and Burroughs AK, 2010. S ystematic review: Portal vein thrombosis in cirrhosis. Aliment Pharmacol Ther; 31: 366-74
  • Lisman T and Porte RJ, 2010. R ebalanced haemostasis in patients with liver disease: Evidence and clinical consequences. Blood; 116(6):878-885.
  • Tripodi A and Mannucci PM, 2007. Abnormalities of haemostasis in chronic liver disease: reappraisal of their clinical significance and the need for clinical and laboratory research. Journal of Hepatology; 46:727-33.
  • Senzolo M, Sartori MT and Lisman T, 200 9. Should we give thromboprophylaxis to patients with liver cirrhosis and coagulopathy? HPB; 11:459-464.
  • Villa E, Camma C, Marietta M et al., 2012. E noxaparin prevents portal vein thrombosis and liv er decompensation in patients with advanced cirrhosis. Gastroenterology; 143:1253-1260.
  • Jairath V and Burroughs AK, 20 13. Anticoagulation in patients with liver cirrhosis: complication or therapeutic opportunity? GUT; 62(4):479-482.
  • Northup PG, McMahon MM, Ruhl AP, et al. Coagulopat hy does not fully protect hospitalized cirrhosis patients from peripheral venous thromboembolism. Am J Gastroenterol. 2006;101(7): 1524-1528.
  • Garcia-Fuster MJ, Abdilla N, Fabia MJ, Fernandez C, Oliver V, Forner MJ. [Venous thromboembolism and liver cirrhosis]. Rev Esp Enferm Dig. 2008;100(5):259-262.
  • Sogaard KK, Horvath-Puho E, Gronbaek H, Jepsen P, Vilstrup H, Sorensen HT. Risk of venous thromboembolism in patients w ith liver disease : a nat ionwide population-based case control study. Am J Gastroenterol. 2009;104(1): 96-101.
  • Tripodi A an d Mannucci PM, 2 011. The coagulopathy of chr onic liver disease; N EN GL J MED ; 365:147-56.
  • Tripodi A, Primignani M, Chantarangkul C et al., 2009. An imbalance of pro vs anti-coagulation factors in plasma from patients with cirrhosis. Gastroenterology;137: 2105-11.
  • Wu H, Ng uyen GC, 2010. Liver cirrhosis is associated w ith venous throm boembolism among hospitalised patients in a nationwide US study. Clin Gastroenterol Hepatol; 8: 800-5.
  • Ali M, Ananthakrishnan AN, Mc Ginley EL et al., 2011. Deep vein thromb osis and pulmona ry embolism in hospitalised patients with cirrhosis: a nationwide analysis; Dig Dis Sci; 56: 2152-9

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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