VTE prophylaxis for long-distance travel
Scottish Intercollegiate Guidelines Network (SIGN), Updated 2014
Long-distance travel refers to travel by air, road or rail for more than 4 hours. However, the association between travel and venous thromboembolism (VTE) (ie deep vein thrombosis [DVT] or pulmonary embolism [PE]) is strongest for air travel lasting longer than 8 to 10 hours, particularly if the traveller has other risk factors for developing VTE. The risk of VTE is increased 2- to 3-fold with long-distance travel, with risk increasing as duration of travel increases, and persisting for up to 8 weeks after travelling. However, the absolute risk of developing travel-related VTE is lowChandra, 2009.
Wearing graduated compression stockings to prevent travel-related VTE is not routinely recommended in patients without a history of VTE or in the absence of additional risk factors for VTE. There is no evidence that graduated compression stockings reduce the incidence of symptomatic DVT or PE, but they may reduce asymptomatic DVT or leg oedema. If a person decides to wear these stockings, they should be professionally fittedClarke, 2016.
Advise all long-distance travellers to remain ambulant if possible before, during and after travelling, and to perform leg exercises while seated. This is particularly important for those at high risk of travel-related VTE (eg patients fitted with a controlled ankle motion [CAM] boot or with other risk factors for VTE).
Do not use pharmacological prophylaxis in long-distance travellers without other risk factors for VTE. Consider pharmacological prophylaxis or graduated compression stockings in patients who are at substantially increased VTE risk Schunemann, 2018.
Commonly used regimens for travel-related VTE prophylaxis are:
1apixaban (CrCl 25 mL/min or more) 2.5 mg orally, 12-hourly apixaban apixaban apixaban
OR
1rivaroxaban (CrCl 15 mL/min or more) 10 mg orally, 24-hourly rivaroxaban rivaroxaban rivaroxaban
OR
2enoxaparinScottish Intercollegiate Guidelines Network (SIGN), Updated 2014 enoxaparin enoxaparin enoxaparin
CrCl 30 mL/min or more: 40 mg subcutaneously, immediately before departure and 24-hourly
CrCl less than 30 mL/min: 20 mg subcutaneously, immediately before departure and 24-hourly.
These anticoagulants have a rapid onset of effect so the first dose should be given the day of departure. The dose may be repeated, depending on the length of the journey and if the patient is immobile on arrival.
At the time of writing, apixaban and rivaroxaban are not available on the Pharmaceutical Benefits Scheme (PBS) for travel-related VTE prophylaxis, unless the patient has previously had a VTE (ie for the prevention of recurrent VTE). See the PBS website for current information.