From the Guidelines
The primary treatment for upper extremity deep venous thrombosis (UEDVT) is anticoagulation therapy, starting with low molecular weight heparin (LMWH) such as enoxaparin 1 mg/kg twice daily subcutaneously, or fondaparinux 7.5 mg once daily subcutaneously, as recommended by the American College of Chest Physicians 1.
Treatment Approach
The treatment approach for UEDVT involves anticoagulation to prevent clot propagation and allow the body's natural fibrinolytic system to dissolve the existing clot.
- Start with LMWH or fondaparinux, as these are preferred over IV UFH due to their predictable anticoagulant effect and reduced need for monitoring 1.
- Transition to oral anticoagulation with a direct oral anticoagulant (DOAC) like rivaroxaban or apixaban, which are preferred over warfarin due to their predictable anticoagulant effect and reduced need for monitoring.
Treatment Duration
- Treatment duration is typically 3 months for provoked UEDVT and at least 3-6 months for unprovoked cases, as suggested by the American College of Physicians and the American Academy of Family Physicians 1.
- Longer treatment may be necessary for ongoing risk factors or recurrent thrombosis.
Additional Measures
- Elevate the affected arm to reduce swelling
- Use compression sleeves if prescribed
- Encourage early mobilization to prevent stiffness In severe cases or those with contraindications to anticoagulation, catheter-directed thrombolysis or surgical thrombectomy may be considered, but these are less common interventions 1.
From the FDA Drug Label
In a multicenter, parallel group study, 900 patients with acute lower extremity deep vein thrombosis (DVT) with or without pulmonary embolism (PE) were randomized to an inpatient (hospital) treatment of either (i) Enoxaparin Sodium Injection 1. 5 mg/kg once a day subcutaneously, (ii) Enoxaparin Sodium Injection 1 mg/kg every 12 hours subcutaneously, or (iii) heparin intravenous bolus (5000 IU) followed by a continuous infusion (administered to achieve an aPTT of 55 to 85 seconds).
The efficacy of XARELTO was generally consistent across major subgroups.
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.
The treatment for upper extremity deep vein thrombosis (DVT) is not directly addressed in the provided drug labels. However, based on the information provided for lower extremity DVT, the following treatments can be considered:
- Enoxaparin Sodium Injection: 1.5 mg/kg once a day subcutaneously or 1 mg/kg every 12 hours subcutaneously 2
- Rivaroxaban (XARELTO): 15 mg twice daily with food for the first three weeks, followed by 20 mg once daily with food 3
- Heparin: intravenous bolus (5000 IU) followed by a continuous infusion (administered to achieve an aPTT of 55 to 85 seconds) 2 It is essential to note that these treatments are for lower extremity DVT, and the treatment for upper extremity DVT may differ. Therefore, a conservative clinical decision would be to consult the latest clinical guidelines or seek expert opinion for the treatment of upper extremity DVT.
From the Research
Treatment Options for Upper Extremity Deep Vein Thrombosis (DVT)
- Anticoagulation therapy is considered the treatment of choice for upper extremity DVT, with heparin or low-molecular-weight heparin followed by warfarin or direct oral anticoagulants (DOACs) 4, 5, 6, 7
- Catheter-directed thrombolysis (CDT) is also a treatment option, which can provide efficient thrombolysis and reduce the risk of postthrombotic syndrome (PTS) 8
- Surgical decompression, percutaneous transluminal angioplasty, and stenting may be used in combination with anticoagulation therapy or CDT in certain cases 4
- The optimal treatment and timing of treatment for upper extremity DVT remains controversial, and early diagnosis and treatment is essential to prevent PTS 4
Treatment Duration and Outcomes
- Anticoagulation therapy is typically continued for 3-6 months, with the goal of preventing recurrent venous thromboembolism and reducing the risk of PTS 4, 5, 6
- The use of DOACs in the treatment of upper extremity DVT has been shown to be effective and safe, with a low risk of recurrence and bleeding complications 7
- CDT has been shown to be effective in restoring venous drainage and reducing the risk of PTS, with a low frequency of mild PTS at follow-up 8