Table 1:

Strategies for VTE Prophylaxis Among Patients With Cancer

Context	Potential Prophylaxis Strategies	Notes
Hospitalized patients
Contraindication to pharmacologic prophylaxis, contraindication or inability to administer mechanical prophylaxis	Early ambulation when possible, patient education, regular reassessment	--This situation is rare --Limited data and guidelines to guide management
Contraindication to pharmacologic prophylaxis, without contraindication to mechanical prophylaxis	Mechanical prophylaxis (sequential compression devices generally preferrred over graduated compression stockings)	--Data to support mechanical methods largely extrapolated from surgical or stroke patients
No contraindications to pharmacologic prophylaxis	Dalteparin, enoxaparin, fondaparinux, subcutaneous unfractionated heparin	-Consult instututional guidelines --Dalteparin and fondaparinux should be avoided if CrCl <30 mL/min, enoxaparin may require dose reduction --Fondaparinux should be avoided in patients <50 kg and caution is needed given the long half-life --Dose adjustments may be needed for obesity --Heparin and related drugs must be avoided for patients with a history of HIT
No contraindicationsto pharmacologic prophylaxis, CrCl<30 mL/min	Subcutaneous unfractionated heparin	--Contraindicated with ahistoryof HIT
No contraindications to pharmacologic prophylaxis, desires daily dosing	LMWH, fondaparinux
Ambulatory Medical Oncology Outpatients with Active Cancer a
Khorana Score <2	Patient eduation	--Pharmacologic prophylaxis is not routinely indicated for low risk patients --It is reasonable to educate patients on the signs/symptoms of VTE and conservative risk reduction strategies
Khorana Score ≥2, acceptable bleeding risk, no drug interactions, receiving/starting systemic therapy	Apixaban, rivaroxaban, dalteparin, enoxaparin	--Avoid if CrCl <30 mL/min or platelets under 50,000 --Avoid apixaban and dalteparin if weight <40 kg --LMWH has largely been studied in advanced unresectable or metastatic pancreatic cancer --DOACs may not be well absorpted in patients with altered gastrointestinal anatomy; patients with gastric and gastroesphageal tumors are likely at increased risk of bleedign with DOACs
Khorana Score ≥2, bleeding risk factors OR prefers not to be on prophylaxis OR unavoidable drug interactions OR significant liver or kidney disease	Patient eduation	--The anticipated benefits of prophylaxis may not outweigh the risks with patients at increased risk for bleeding --Drug interactions, bleeding risk, organ dysfuntion, or other factors may preclude pharmacologic VTE prophylaxis

^a:Exculdes multiple myeloma, acute leukemia, myeloproliferative neoplasms, primary or metastatic brain tumors. See text for details, Abbreviations: CrCl, creatinine clearance; DOACs, direct oral anticoagulants; kg, kilograms; VTE, venous thromboembolism