What is the current prophylaxis of venous thromboembolism (VTE) in healthy long-distance travelers? What are the evidence-based recommendations? What recommendations would you give to such patients?
Jeffrey Weitz: Of course, everybody thinks about long-distance travel as a risk factor for thrombosis, particularly for deep vein thrombosis, possibly also complicated by pulmonary embolism. Although it occurs, it is rare. If you think of the millions of travelers who are on long-distance flights, very few of them will actually get VTE. So I think it is a disease that gets a lot of attention, but it is actually a pretty rare disorder.
What do I tell my patients? If a patient has a prior history of VTE, if they are still on anticoagulants, then they are protected, they do not have to worry. If they have had a history of a travel-associated VTE in the past and they are off anticoagulants, it may be prudent to give them an anticoagulant before they get on the plane. You could either use an injection of low-molecular-weight heparin or you could give a dose of rivaroxaban, for example, a 20 mg tablet will cover them for 24 hours; even a 10 mg tablet for prophylaxis. Do we have any data supporting that? No. Is it prudent, sensible? Yes.
For most patients I tell them that yes, there is a risk, and what they should do when they are sitting in their seat, they should do simple exercises – as recommended in the brochure in their seat back that they never read – just to do foot exercises to keep the calf muscles contracting, get up and walk along the corridor, not just to sit in their seat for the whole hour. Remember, these long-distance flights are flights that are over 7 hours in length, so most flights within Europe or North America are too short to increase the risk.
So I think it is an overblown problem. It does occur. We know that aspirin has not been shown to be effective. Greater compression stockings may be effective – we do not know that. I think that patients should just be advised to do foot exercises, to walk, and possibly, if the are very concerned, to take a prophylactic dose of an anticoagulant, either injected or oral, before the flight.