Abstract
Current guideline recommendations for primary prophylaxis of venous thromboembolism
(VTE) are based on randomized clinical trials that usually exclude subjects at a potentially
high risk of bleeding complications. For this reason, no specific guideline is available
for thromboprophylaxis in hospitalized patients with thrombocytopenia and/or platelet
dysfunction. However, except in patients with absolute contraindications to anticoagulant
drugs, antithrombotic prophylaxis should always be considered, for example, in hospitalized
cancer patients with thrombocytopenia, especially in those with multiple VTE risk
factors. Low platelet number, platelet dysfunction, and clotting abnormalities are
also very common in patients with liver cirrhosis, but these patients have a high
incidence of portal venous thrombosis, implying that cirrhotic coagulopathy does not
fully protect against thrombosis. These patients may benefit from antithrombotic prophylaxis
during hospitalization. Patients hospitalized for COVID-19 need prophylaxis, but frequently
experience thrombocytopenia or coagulopathy. In patients with antiphospholipid antibodies,
a high thrombotic risk is usually present, even in the presence of thrombocytopenia.
VTE prophylaxis in high-risk conditions is thus suggested in these patients. At variance
with severe thrombocytopenia (< 50,000/mm3), mild/moderate thrombocytopenia (≥ 50,000/mm3) should not interfere with VTE prevention decisions. In patients with severe thrombocytopenia,
pharmacological prophylaxis should be considered on an individual basis. Aspirin is
not as effective as heparins in lowering the risk of VTE. Studies in patients with
ischemic stroke demonstrated that thromboprophylaxis with heparins is safe in these
patients also during antiplatelet treatment. The use of direct oral anticoagulants
in the prophylaxis of VTE in internal medicine patients has been recently evaluated,
but no specific recommendation exists for patients with thrombocytopenia. The need
for VTE prophylaxis in patients on chronic treatment with antiplatelet agents should
be evaluated after assessing the individual risk of bleeding complications. Finally,
the selection of patients who require post-discharge pharmacological prophylaxis remains
debated. New molecules currently under development (such as the inhibitors of factor
XI) may contribute to improve the risk/benefit ratio of VTE primary prevention in
this setting of patients.
Keywords
venous thromboembolism - prophylaxis - thrombocytopenia - low-molecular-weight heparin
