Background: Acutely ill hospitalized medicine patients are at increased risk for venous thromboembolism (VTE) and chemoprophylaxis of VTE is recommended for this patient population. Agents typically used for VTE chemoprophylaxis include unfractionated heparin and low molecular weight heparin (LMWH) administered via subcutaneous injection one to three times daily. Over the past decade, new evidence is emerging that direct oral anticoagulants (DOACs) such as rivaroxaban are effective and safe oral options for VTE chemoprophylaxis in appropriately selected inpatients. DOACs present an appealing oral option because they do not require painful daily injections and have the potential to improve patient satisfaction and compliance with VTE chemoprophylaxis while admitted. Here we present a single institution’s experience with oral rivaroxaban for chemoprophylaxis of VTE in hospitalized medicine patients.
Methods: Beginning in April 2021 rivaroxaban 10mg was added to inpatient order sets as an option for VTE chemoprophylaxis. Licensed independent practitioners (LIPs) consisting of resident physicians and hospitalists caring for patients on the inpatient general medicine service at the University of Virginia were provided education regarding use of rivaroxaban 10 mg daily for chemoprophylaxis in appropriately selected patients. Contraindications to rivaroxaban included patients receiving dual antiplatelet therapy, renal insufficiency with creatinine clearance <30 mL/min, and Child-Pugh class B or C liver disease. Rivaroxaban and the above contraindications were added to the routine VTE chemoprophylaxis order set in the hospital electronic medical record (EMR). Five months later, LIPs were asked to complete an anonymous survey about their ordering practices and opinions regarding the use of rivaroxaban for VTE chemoprophylaxis.
Results: Forty-six LIPs responded to the aforementioned survey. Of respondents, 45.7% had previously ordered rivaroxaban for VTE chemoprophylaxis. Major barriers reported by LIPs included periprocedural concerns, with 54.3% of respondents avoiding rivaroxaban if there was any chance their patient could need a procedure while hospitalized. Seventeen percent of LIPs reported having had a procedure delayed due to their patient receiving a DOAC. Forty-four percent of LIPs avoided ordering rivaroxaban because they were unfamiliar with the safety data, efficacy data, or contraindications for using DOACs for VTE chemoprophylaxis. Despite this, 76.1% of LIPs were open to using rivaroxaban for VTE chemoprophylaxis in the future.
Conclusions: Despite recent studies showing that DOACs are safe and effective forms of VTE chemoprophylaxis for acutely ill hospitalized medicine patients, they have not been widely adopted for use in the inpatient setting. Our data suggests that the primary reason for hesitancy to use a DOAC is concern about periprocedural management of this medication and risk of procedural delays. Other barriers included lack of LIP comfort with indications and contraindications for its use. Future directions include updating periprocedural guidelines to avoid unnecessary delays in inpatient procedures and incorporating more clear indications/contraindications into the health system EMR order set.