From the Guidelines
Deep vein thrombosis (DVT) treatment should primarily involve a 3-month treatment phase of anticoagulation, as recommended by the most recent guidelines 1. The treatment of DVT typically begins with a parenteral anticoagulant such as low molecular weight heparin (LMWH), most commonly enoxaparin at 1 mg/kg twice daily or 1.5 mg/kg once daily. This is often overlapped with a direct oral anticoagulant (DOAC) like apixaban, rivaroxaban, or edoxaban. Alternatively, warfarin can be used with a target INR of 2-3, but requires more monitoring. Key considerations in DVT treatment include:
- Initial treatment with anticoagulation to prevent clot extension and recurrence
- Use of LMWH or DOACs as first-line treatment options
- Treatment duration of at least 3 months for provoked DVT and consideration for extended therapy in unprovoked or high-risk cases
- Regular follow-up to monitor treatment efficacy and bleeding complications
- Consideration of compression stockings and early mobilization to reduce post-thrombotic syndrome symptoms and improve outcomes, as suggested by previous guidelines 1. Upon completion of the 3-month treatment phase, all patients should be assessed for extended-phase therapy, taking into account their individual risk factors and bleeding risks 1.
From the FDA Drug Label
XARELTO is a factor Xa inhibitor indicated: ... for treatment of deep vein thrombosis (DVT) ( 1.2) Treatment of DVT and/or PE: 15 mg orally twice daily with food for the first 21 days followed by 20 mg orally once daily with food for the remaining treatment ( 2.1) EINSTEIN Deep Vein Thrombosis and EINSTEIN Pulmonary Embolism Studies XARELTO for the treatment of DVT and/or PE was studied in EINSTEIN DVT [NCT00440193] and EINSTEIN PE [NCT00439777], multi-national, open-label, non-inferiority studies comparing XARELTO (at an initial dose of 15 mg twice daily with food for the first three weeks, followed by XARELTO 20 mg once daily with food) to enoxaparin 1 mg/kg twice daily for at least five days with VKA and then continued with VKA only after the target INR (2.0–3. 0) was reached. In the EINSTEIN DVT and EINSTEIN PE studies, XARELTO was demonstrated to be non-inferior to enoxaparin/VKA for the primary composite endpoint of time to first occurrence of recurrent DVT or non-fatal or fatal PE [EINSTEIN DVT HR (95% CI): 0.68 (0.44,1.04); EINSTEIN PE HR (95% CI): 1.12 (0.75,1. 68)].
Treatment of DVT: Rivaroxaban (XARELTO) is indicated for the treatment of deep vein thrombosis (DVT) and is administered at a dose of 15 mg orally twice daily with food for the first 21 days, followed by 20 mg orally once daily with food for the remaining treatment.
- The recommended dosage is 15 mg twice daily for 21 days, then 20 mg once daily.
- Rivaroxaban has been shown to be non-inferior to enoxaparin/VKA in the treatment of DVT, with a hazard ratio of 0.68 (95% CI: 0.44,1.04) in the EINSTEIN DVT study 2 2.
From the Research
Treatment of DVT
- The treatment of Deep Vein Thrombosis (DVT) typically involves anticoagulation therapy to prevent recurrence and reduce the risk of pulmonary embolism 3, 4.
- A study published in the journal Blood found that increasing proportions of time on heparin with an activated partial thromboplastin time (APTT) ≥ 0.2 anti-X(a) U/mL and on warfarin with an international normalized ratio (INR) ≥ 2.0 were associated with significant reductions in VTE recurrence 3.
- The American Family Physician recommends direct oral anticoagulants as first-line agents for eligible patients for treating venous thromboembolism and preventing stroke in those with nonvalvular atrial fibrillation, while vitamin K antagonists are recommended for patients with mechanical valves and valvular atrial fibrillation 4.
- Low-molecular-weight heparin is also recommended as a first-line treatment for patients with venous thromboembolism and active cancer, although there is growing evidence of effectiveness for the use of direct oral anticoagulants in this patient population 4.
Anticoagulation Management
- Validated bleeding risk assessments such as HAS-BLED should be performed at each visit and modifiable factors should be addressed 4.
- Major bleeding should be treated with vitamin K and 4-factor prothrombin complex concentrate for patients already being treated with a vitamin K antagonist, and idarucizumab or andexanet alfa can be used to reverse the anticoagulant effects of certain direct oral anticoagulants 4.