Clinical and economic aspects of managing venous thromboembolism in the outpatient setting

Low-molecular-weight heparins (LMWHs) are at least as effective and safe as unfractionated heparin (UFH) in the prevention and initial treatment of venous thromboembolism (VTE), and their fixed-dose, once- or twice-daily dosing regimen without laboratory monitoring makes them suitable for outpatient use. Postoperative thromboprophylaxis usually continues until hospital discharge, but evidence demonstrates that the VTE risk persists for several weeks. Economic pressures, changes in clinical practice, and patient preferences make hospital stays shorter. As a result, outpatient thromboprophylaxis with LMWH has been investigated. LMWH self-administered at home once daily for up to 4 weeks after hospital discharge is safe and well tolerated and significantly reduces the incidence of postdischarge VTE after hip replacement. Targeted appropriately, extended thromboprophylaxis may be cost effective, and the development of an autoinjection device may increase the proportion of patients eligible for home management. LMWHs may also be of value as long-term secondary thromboprophylaxis in patients with contraindications to oral anticoagulants. Standard initial treatment for VTE comprises intravenous UFH administered to the patient in the hospital. However, three large-scale studies have demonstrated the efficacy and safety of outpatient treatment of acute VTE using LMWHs. The economic benefits of shortening or eliminating inpatient therapy are substantial, but successful home treatment requires careful patient selection, intensive education and a comprehensive system of professional support to optimize compliance and safety.