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Letter to the Editor

Editor, – Further to the article by the NSW Therapeutic Advisory Group (Aust Prescr 2009;32:108–12), we would like to draw your attention to the recently updated position statement 'Safe use of heparins and oral anticoagulants for venous thromboembolism prophylaxis in adults' (

The position statement aligns with the National Health and Medical Research Council 2009 Clinical Practice Guideline for the prevention of venous thromboembolism in patients admitted to Australian hospitals, and includes updated information on oral anticoagulants approved for venous thromboembolism prophylaxis and assessing renal function.

With growing Australian and international encouragement for instituting venous thromboembolism prophylaxis systems in hospitals, it can be expected that an increased number of inpatients will be prescribed venous thromboembolism prophylaxis.

However, heparins (even in a low dose) and oral anticoagulants carry a risk of causing bleeding from any site, especially in patients at increased risk of bleeding from other causes such as concurrent administration of some medicines, some clinical conditions and some surgical and anaesthetic procedures. Careful clinical management of patients at risk of bleeding is required to minimise the risk and severity of bleeding related to venous thromboembolism prophylaxis.

Six steps for safe provision of venous thromboembolism prophylaxis are outlined:

Step 1: Identify patients requiring venous thromboembolism prophylaxis
Step 2: Assess for bleeding risk and contraindications
Step 3: Assess for special precautions

3.1 Renal impairment

3.2 Concomitant medicines

3.3 Determine if neuraxial (spinal/epidural) anaesthesia is planned

3.4 Obesity
Step 4: Select the most appropriate heparin or anticoagulant agent
Step 5: Determine appropriate timing of venous thromboembolism prophylaxis
Step 6: Monitor for adverse events.

While this document aims to guide clinical practice, it is not intended to replace clinician judgement. Many decisions for venous thromboembolism prophylaxis need to be made on an individual patient basis. These are highlighted clearly in the text.

Paul Seale

Gillian Campbell
Executive Officer

NSW Therapeutic Advisory Group
Darlinghurst, NSW