What is the immediate treatment for a patient diagnosed with Deep Vein Thrombosis (DVT)?

From the Guidelines

The immediate treatment for a patient diagnosed with Deep Vein Thrombosis (DVT) is anticoagulation therapy, which should be initiated with a parenteral anticoagulant and an oral anticoagulant simultaneously, with a preference for direct oral anticoagulants (DOACs) over vitamin K antagonists (VKAs) for primary treatment, as recommended by the American Society of Hematology 2020 guidelines 1. The treatment 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 subcutaneously, or unfractionated heparin as an intravenous infusion. Simultaneously, an oral anticoagulant is started, either a DOAC like rivaroxaban (15 mg twice daily for 21 days, then 20 mg once daily), apixaban (10 mg twice daily for 7 days, then 5 mg twice daily), or warfarin (dose adjusted to maintain INR between 2-3). The parenteral anticoagulant is continued until the oral agent reaches therapeutic levels, which for warfarin means at least 5 days and until the INR is ≥2.0 for 24 hours. Patients should also be advised to elevate the affected limb, apply warm compresses, and take analgesics as needed for pain. Compression stockings may be recommended to reduce swelling. Anticoagulation prevents the existing clot from growing larger and reduces the risk of pulmonary embolism by stopping new clots from forming. The treatment duration typically ranges from 3-6 months but may be longer depending on risk factors for recurrence, as suggested by guidelines from the Journal of Thrombosis and Haemostasis 1 and Chest 1. Patients should be monitored for bleeding complications, which are the main risk of anticoagulation therapy. It is also important to consider the guidelines for treatment and prevention of venous thromboembolism among patients with cancer, which recommend LMWH as the preferred initial treatment, as stated in Thrombosis Research 1. However, the most recent and highest quality study, the American Society of Hematology 2020 guidelines 1, should be prioritized when making treatment decisions. Key points to consider in the treatment of DVT include:

• Initiation of anticoagulation therapy with a parenteral anticoagulant and an oral anticoagulant simultaneously
• Preference for DOACs over VKAs for primary treatment
• Treatment duration of at least 3-6 months
• Monitoring for bleeding complications
• Consideration of guidelines for treatment and prevention of venous thromboembolism among patients with cancer.

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). All patients also received warfarin sodium (dose adjusted according to PT to achieve an International Normalization Ratio [INR] of 2.0 to 3.0), commencing within 72 hours of initiation of enoxaparin sodium injection or standard heparin therapy, and continuing for 90 days. Enoxaparin sodium injection or standard heparin therapy was administered for a minimum of 5 days and until the targeted warfarin sodium INR was achieved Both enoxaparin sodium injection regimens were equivalent to standard heparin therapy in reducing the risk of recurrent venous thromboembolism (DVT and/or PE).

The immediate treatment for a patient diagnosed with Deep Vein Thrombosis (DVT) is:

• Enoxaparin sodium injection 1.5 mg/kg once a day subcutaneously or 1 mg/kg every 12 hours subcutaneously
• Heparin intravenous bolus (5000 IU) followed by a continuous infusion (administered to achieve an aPTT of 55 to 85 seconds)
• Warfarin sodium (dose adjusted according to PT to achieve an INR of 2.0 to 3.0), commencing within 72 hours of initiation of enoxaparin sodium injection or standard heparin therapy, and continuing for 90 days. Key points to consider:
• The treatment should be administered for a minimum of 5 days and until the targeted warfarin sodium INR is achieved.
• The choice of treatment regimen may depend on individual patient factors and clinical judgment. 2

From the Research

Immediate Treatment for Deep Vein Thrombosis (DVT)

The immediate treatment for a patient diagnosed with DVT involves anticoagulation to control symptoms, prevent progression, and reduce the risk of post-thrombotic syndrome and pulmonary embolism 3.

Anticoagulation Options

• Anticoagulation may consist of a parenteral anticoagulant overlapped by warfarin or followed by a direct oral anticoagulant (DOAC) (dabigatran or edoxaban), or of a DOAC (apixaban or rivaroxaban) without initial parenteral therapy 3.
• Low-molecular-weight heparin (LMWH) is also a common initial antithrombotic therapy for DVT, with advantages including fixed-dose administration and a more convenient route of administration 4.
• Unfractionated heparin has documented efficacy in reducing mortality and recurrent thromboembolic events in patients with pulmonary embolism or symptomatic proximal (above-knee) DVT 4.

Considerations for Anticoagulation Therapy

• DOACs are the preferred treatment for DVT because they are at least as effective, safer, and more convenient than warfarin 3.
• However, DOACs may require dose reduction or avoidance in patients with renal dysfunction, and should be avoided in pregnancy 3.
• The choice of anticoagulation therapy should be based on the patient's predisposing risk factors and risk of event recurrence 5.

Additional Considerations

• Thrombolysis may be useful in case of massive pulmonary embolism, but more evaluation is needed 4.
• Bleeding and heparin thrombocytopenia are the main adverse effects of anticoagulation therapy 4.
• Enoxaparin, a LMWH, has been shown to provide better outcomes than unfractionated heparin in the treatment of unstable angina and non-ST-segment elevation myocardial infarction, without increasing major bleeding 6.