Although they are less likely to receive it, patients hospitalized with inflammatory bowel disease (IBD) should be placed on venous thromboembolism (VTE) prophylaxis to reduce the number of preventable VTE events in this patient population, according to research published in Inflammatory Bowel Disease.
Researchers conducted a retrospective cohort study of hospitalized patients with IBD to assess why VTE prophylaxis prescription rates remain low despite an increased risk for VTE in this patient population. The study included adult patients admitted to either general medicine or colorectal surgery services for ≥48 hours between January 2013 and August 2018. Automated queries were used to identify the demographic and baseline information contained in the electronic medical records.
The total cohort included 22,499 patients, 2.1% of whom had IBD. Among patients with IBD, 43.7% had ulcerative colitis, 55.3% had Crohn disease, and 1.0% had indeterminate colitis. A majority of these patients were younger than 50 years (26% aged between 18 and 30 years). Of the 22,025 patients without IBD, 87% received pharmacologic VTE prophylaxis, compared with 79% of patients with IBD.
The results of a multivariate analysis of all patients demonstrated that older age, multiple comorbidities, being a woman, and VTE history were all associated with a likelihood of receiving VTE prophylaxis. Conversely, anemia, thrombocytopenia, and admission to a medical rather than surgical service were associated with a reduced likelihood of receiving the same prophylactic treatment. The presence of IBD was also significantly associated with a decreased likelihood of VTE prophylaxis (adjusted odds ratio 0.57; 95% CI, 0.44-0.73), but when hematochezia was included in the final model, IBD was no longer independently related to VTE prophylaxis.
Among patients with IBD, VTE prophylaxis rates were lower in those experiencing an IBD flare compared with those without (76% vs 85%, respectively). A univariate analysis identified hematochezia, admission to medical service, and initial hemoglobin <7 g/dL as factors associated with a decreased likelihood of receiving VTE prophylaxis. In a final multivariable model, these same predictors remained significantly associated with a decreased likelihood of receiving VTE prophylaxis. Results were similar after they were stratified for ulcerative colitis and Crohn disease. In addition, hematochezia was one of the strongest predictors of decreased likelihood of VTE prophylaxis (adjusted odds ratio 0.27; 95% CI, 0.16-0.46).
Due to its strong association, investigators further assessed the clinical significance of hematochezia in IBD. No statistically significant differences were found in transfusion requirements between patients with and without hematochezia. Among those with hematochezia, 17% required any packed red blood cell (pRBC) transfusion during hospitalization, and 5.4% required ≥3 pRBC transfusions when hematochezia was present; for those without hematochezia, these numbers were 13% and 6.6%.
Investigators also examined the extent of bleeding during patient hospitalization and how it impacted VTE prophylaxis. Among those with IBD, 14% who received VTE prophylaxis also required pRBC transfusion, compared with 15% of those who did not receive VTE prophylaxis.
Finally, researchers investigated 112 patients with both IBD and hematochezia, comparing the transfusion and hemoglobin requirements between those who received VTE prophylaxis and those who did not. There were no significant differences in initial hemoglobin values between patients who did and patients who did not receive VTE prophylaxis. Among those who did receive VTE prophylaxis, 19% required a pRBC transfusion and 5% required ≥ 3 pRBC transfusions, compared with 14% and 6.1% of those who did not receive VTE prophylaxis.
Study limitations included the observational nature of the study and a potential lack of generalizability based on the use of a single center. Finally, the data were not powered to quantify the net risk-benefit of VTE prophylaxis in IBD.
“To limit the number of preventable VTE events, educational efforts should emphasize the importance and safety of prophylaxis in [patients with IBD], including those with hematochezia,” the researchers concluded.
Faye AS, Hung KW, Cheng K, et al. Minor hematochezia decreases use of venous thromboembolism prophylaxis in patients with inflammatory bowel disease [published online November 5, 2019]. Inflamm Bowel Dis. doi: 10.1093/ibd/izz269