Are we Overusing LMWH?

Low-molecular-weight heparins (LMWHs) have become a near-routine prescription for venous thromboembolism (VTE) prevention in hospitalized patients in several parts of the world. Their use may be reinforced by embedded order sets and ‘opt-out’ defaults. However, the absolute clinical benefit of universal pharmacologic thromboprophylaxis for many low-risk medical inpatients appears small. Symptomatic VTE rates are low, mortality benefits with LMWH use are not clearly demonstrated, and any reductions in thrombotic events may be offset by bleeding complications. Several analyses suggest that a substantial proportion of patients classified as ‘low-risk’ by validated risk-assessment models still receive LMWH prophylaxis in practice. LMWH also carries a largely overlooked environmental footprint because it is derived almost exclusively from porcine intestinal mucosa via resource-intensive and low-yield manufacturing processes. It is also compounded by single-use injection materials and downstream monitoring requirements. We propose that ‘sustainable thromboprophylaxis’ should be framed within appropriate, value-based healthcare. We should prioritize LMWH for patients who meaningfully benefit, reducing potentially avoidable use in low-risk settings and explicitly accounting for environmental impact as a co-consideration where clinical benefit is marginal. Achieving this requires better VTE risk stratification integrated into workflows and formal life cycle assessment to quantify the carbon costs and supply chain vulnerabilities of current high-volume anticoagulantion practice.