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BMJ. 2007 June 2; 334(7604): 1127.
PMCID: PMC1885292
Thromboprophylaxis for Adults in Hospital

A mess for medical patients

Craig G Morris, consultant intensivist and anaesthetist

The editorial by Fitzmaurice and Murray is timely and welcome,1 but I share many of D'Costa's concerns about the ease with which we slide between the evidence for surgical and medical prophylaxis. We are in a strong position with evidence of efficacy to provide prophylaxis for high risk medical patients, and the “high risk” criteria mandated by D'Costa seem almost identical to the list from the National Institute for Health and Clinical Excellence (NICE) for surgical patients at risk. This debate should move on and medical patients with easily identified risk factors receive prophylaxis of a comparable level to their surgical comparators (enoxoparin 40 mg, fondaparinux, or similar, with pneumatic compression). If the medical community wish to target at risk medical patients, then why not use the NICE surgical criteria and cross out the word “surgical”?

One of the references in the editorial and carried by the BMJ—the fondaparinux study by the ARTEMIS investigators—is troubling me.2 This study, which confirmed efficacy of fondaparinux in medical patients with risk factors, was placebo controlled. Surely this should have been run as a non-inferiority study against enoxoparin 40 mg?3The excess of deaths in the placebo group was unacceptable and avoidable and should put an end to our debating over whether at risk medical patients should receive prophylaxis at all.


Competing interests: None declared.


1. Fitzmaurice DA, Murray E. Thromboprophylaxis for adults in hospital. BMJ 2007;334:1017-8. (19 May.) . [PMC free article] [PubMed]
2. Cohen AT, Davidson BL, Gallus AS for the ARTEMIS Investigators. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older medical patients: randomised placebo controlled trial. BMJ 2006;332:325- 9. [PMC free article] [PubMed]
3. Samama MM, Cohen AT, Darmon JY, Desjardins L, Eldor A, Janbon C, et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. Prophylaxis in Medical Patients with Enoxaparin Study Group. N Engl J Med 1999;341:793-800 [PubMed]

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