6th July 2026

Important considerations for VTE treatment (PE and DVT)

PE with haemodynamic instability 

• Unfractionated heparin infusion or thrombolysis

Renal impairment, active malignancy, or antiphospholipid syndrome 

Medications may be unlicenced so seek specialist advice

Renal impairment: calculate creatinine clearance and prescribe as per NICE or local trust policy

Active cancer: consider initial treatment with DOAC

Antiphospholipid syndrome: LMWH and a vitamin K antagonist (e.g., warfarin) for either 5 days or until INR > 2 on two consecutive readings, then vitamin K antagonist alone 

Body weight

• If patient is <50 kg or >120kg, consider monitoring of therapeutic levels of anticoagulation – seek specialist advice 

Investigations to guide treatment

• Full blood count, renal function, liver function, coagulation screen (PT, APTT, INR)
• Do not delay urgent treatment whilst awaiting results, but may need doses adjusting subsequently 

Medical management for patients without renal impairment, active malignancy, antiphospholipid syndrome, who are haemodynamically stable

• Apixaban and rivaroxaban advised by NICE
• If contraindicated, refer to trust guidelines and seek specialist advice 

Length of treatment

• At least 3 months of treatment should be considered for the majority of patients 
• Patients with underlying comorbidities such as active malignancy may require longer duration of treatment (up to 6 months). Treatment should be reviewed after 3 months 

Monitoring 

• Requires monitoring by a community or hospital team, depending on local services and policy 
• Self-monitoring of INR and dose adjustment should not be routinely offered 

Treatment failure

• If treatment fails (i.e., patient develops a further VTE on treatment), check compliance with treatment, screen for other causes of hypercoagulability, consider dose adjustments, or consider changing to an alternative anticoagulant