What is the recommended therapeutic prophylaxis for Deep Vein Thrombosis (DVT)?

Therapeutic Prophylaxis for Deep Vein Thrombosis (DVT)

For DVT prophylaxis, initial treatment with parenteral anticoagulation using low-molecular-weight heparin (LMWH), fondaparinux, or unfractionated heparin (UFH) is recommended, followed by transition to direct oral anticoagulants (DOACs) for non-cancer patients or continued LMWH for cancer patients. 1, 2

Initial Anticoagulation Options

Preferred Agents

• LMWH (first-line for most patients):

  • Enoxaparin: 40 mg subcutaneously daily for prophylaxis; 1 mg/kg twice daily or 1.5 mg/kg once daily for treatment 1, 2
  • Dalteparin: 5000 U subcutaneously daily for prophylaxis; 200 U/kg once daily for treatment 1
  • Tinzaparin: 4500 U or 75 U/kg subcutaneously daily for prophylaxis; 175 U/kg once daily for treatment 1, 2

• Fondaparinux: 2.5 mg subcutaneously daily for prophylaxis; weight-based dosing for treatment (5-10 mg based on weight) 1, 3

  • May be preferred over LMWH for superficial vein thrombosis (Grade 2C) 1

• Unfractionated heparin (UFH): 5000 U subcutaneously every 8 hours for prophylaxis; 80 U/kg IV bolus followed by 18 U/kg/hour IV for treatment 1, 2

  • Reserved for patients with severe renal impairment or when rapid reversal might be needed 2

Long-term Anticoagulation

For Non-Cancer Patients

• DOACs (preferred over vitamin K antagonists):
  • Rivaroxaban: 15 mg twice daily for 21 days, then 20 mg once daily 2, 4
  • Apixaban: 10 mg twice daily for 7 days, then 5 mg twice daily 2, 5
  • Edoxaban: Initial LMWH for ≥5 days, then 60 mg once daily 2
  • Dabigatran: Initial LMWH for ≥5 days, then 150 mg twice daily 2

For Cancer Patients

• LMWH is preferred over vitamin K antagonists (Grade 2B) 1
  • Dalteparin: 200 U/kg once daily for the first month, then 150 U/kg once daily 1, 2
  • Other LMWHs at therapeutic doses

Duration of Anticoagulation

• Provoked DVT (by surgery or transient risk factor): 3 months (Grade 1B) 1, 2
• Unprovoked DVT: Extended therapy recommended (Grade 2B) 1, 2
• DVT with active cancer: Extended therapy recommended (Grade 1B) 1
• High bleeding risk: Limit to 3 months (Grade 1B) 1, 2
• Annual reassessment for patients on extended therapy 2

Special Considerations

Upper Extremity DVT

• For axillary or more proximal UEDVT: Minimum 3 months of anticoagulation (Grade 2B) 1
• For catheter-related UEDVT:
  • If catheter removed: 3 months of anticoagulation (Grade 1B for non-cancer; Grade 2C for cancer) 1
  • If catheter remains: Continue anticoagulation as long as catheter is present (Grade 1C for cancer; Grade 2C for non-cancer) 1

Superficial Vein Thrombosis

• For SVT ≥5 cm: Prophylactic dose of fondaparinux or LMWH for 45 days (Grade 2B) 1
• Fondaparinux 2.5 mg daily preferred over LMWH (Grade 2C) 1

Massive DVT

• Consider thrombolysis for extensive iliofemoral DVT with severe symptoms and recent onset (<24 hours) 2
• Consider invasive approaches (thrombus fragmentation) where facilities and expertise are available 2

Adjunctive Measures

• Compression stockings: Consider within 1 month of diagnosis and continue for at least 1 year to prevent post-thrombotic syndrome 2
• Early mobilization: Recommended over bed rest unless pain and edema are severe 2
• IVC filters: Not recommended as routine addition to anticoagulation; consider only if absolute contraindication to anticoagulation exists 2

Monitoring

• Baseline testing: Complete blood count, renal and hepatic function panel, aPTT, and PT/INR
• Follow-up monitoring: Hemoglobin, hematocrit, and platelet count every 2-3 days for the first 14 days, then every 2 weeks 2

Cautions and Contraindications

• DOACs should be avoided in:

  • Antiphospholipid syndrome 2
  • Severe renal impairment 2, 5
  • Cancer patients with gastrointestinal malignancies (rivaroxaban and edoxaban) 2

• Contraindications for outpatient treatment:

  • Active bleeding, recent major surgery/trauma, thrombocytopenia, coagulopathy 2
  • Severe pain requiring parenteral analgesia, significant comorbidities 2

The choice of anticoagulant should consider patient-specific factors including renal function, cancer status, bleeding risk, and medication interactions. While newer DOACs offer convenience advantages, LMWH remains the standard for cancer patients and those with certain high-risk conditions.