3rd April 2024

Management

Offer either a DOAC or LMWH as a choice of anticoagulant based on the clinical scenario. The duration of anticoagulation therapy is for three months in patients with a provoked DVT/PE when the provoking factor is no longer present. Consider anticoagulation beyond three months in unprovoked DVT/PE based on future VTE risk and bleeding risk. If anticoagulation is contraindicated in patients with DVT/PE, an inferior vena cava filter should be considered. For patients with confirmed PE and haemodynamic instability, treatment options include unfractionated heparin infusion and thrombolytic therapy. 

Catheter-guided thrombolytic therapy for symptomatic iliofemoral DVT may be considered in those with symptoms < 14 days, with good functional status, life expectancy of more than one year and with low bleeding risk. Do not offer further investigations for cancer to patients unless they have other clinical indications. Do not offer thrombophilia testing for patients continuing on anticoagulation or have had provoked VTE.

Anticoagulation

Various anticoagulation options are available to treat VTE, and choice should be based on clinical scenario and patient preference.

Apixaban and Rivaroxaban can be started at initial suspicion or after diagnosis without bridging LMWH.

• Apixaban 10mg BD for 7 days followed by 5mg BD
• Rivaroxaban 15mg BD for 21 days followed by 20mg OD

Dabigatran and Edoxaban require bridging with LMWH for at least 5 days before initiating.

LMWH should be used concurrently when initiating a Vitamin K antagonist until the INR is at least 2.0 for 2 consecutive readings.

Unfractionated heparin may be used in severe renal impairment or in patients with high bleeding risk.

Prophylaxis

Hospital-acquired VTE refers to a VTE that occurs within 90 days of hospital admission. All patients should have a VTE risk assessment on admission to hospital to ensure adequate prophylaxis, either mechanical or pharmacological, is prescribed. Mechanical prophylaxis includes graduated compression stockings and intermittent pneumatic compression devices (IPC). IPC devices should be used for patients admitted with an acute stroke, initiated within three days and continued for 30 days or until sufficiently mobile. Mechanical prophylaxis is appropriate for patients with major trauma or undergoing cranial, spinal, thoracic, cardiac or ENT surgery. Pharmacological prophylaxis includes heparins (unfractionated or low molecular weight) and DOAC in specific scenarios.