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

Treatment of Deep Vein Thrombosis (DVT)

The recommended treatment for DVT is anticoagulation therapy, with direct oral anticoagulants (DOACs) preferred over vitamin K antagonists (VKAs) for most patients, and treatment duration of at least 3 months for provoked DVT and 6-12 months or longer for unprovoked DVT. 1

Initial Anticoagulation Approach

For Proximal DVT (popliteal vein and above):

• Immediate anticoagulation is strongly recommended due to higher risk of progression to pulmonary embolism 1
• Initial treatment options:
  • Low-molecular-weight heparin (LMWH): 1 mg/kg subcutaneously every 12 hours 2
  • Unfractionated heparin (UFH): 80 U/kg or 5,000 units IV bolus, followed by 18 U/kg/hour continuous infusion (target aPTT 1.5-2.5 times control) 1
  • Fondaparinux (alternative option) 1

For Distal DVT (below popliteal vein):

• For patients with severe symptoms or risk factors for extension (positive D-dimer, thrombus close to proximal veins, active cancer, inpatient status): immediate anticoagulation 1
• For patients without severe symptoms or risk factors: serial imaging of deep veins for 2 weeks may be considered instead of immediate anticoagulation 1
  • If thrombus extends into proximal veins during monitoring, initiate anticoagulation 1

Maintenance Therapy

Preferred Options (in order):

1. Direct Oral Anticoagulants (DOACs): Apixaban, dabigatran, edoxaban, or rivaroxaban 1
2. Vitamin K Antagonists (VKAs): Warfarin with target INR 2.0-3.0 3

Transition from Initial to Maintenance Therapy:

• If starting with heparin/LMWH, transition to oral anticoagulation after 5-7 days 1
• When transitioning to warfarin:
  • Continue heparin/LMWH overlap for at least 5 days and until INR is therapeutic (2.0-3.0) for 24 hours 1, 3
• When transitioning to DOACs:
  • No overlap needed; start DOAC when next LMWH dose would be due or when stopping IV heparin 1

Treatment Duration

• Provoked DVT (associated with transient risk factor like surgery): minimum 3 months 1, 3
• Unprovoked DVT (no clear trigger): 6-12 months or indefinite therapy 1, 3
• Recurrent DVT (two or more episodes): indefinite treatment recommended 3
• DVT with thrombophilia (antiphospholipid antibodies, protein C/S deficiency, Factor V Leiden, etc.): 6-12 months to indefinite therapy 3

Special Populations

Cancer Patients:

• LMWH preferred over VKAs for long-term therapy 1
• Consider dose reduction to 75-80% of initial dose after the first month 1
• Continue anticoagulation at least until resolution of underlying disease 4

Antiphospholipid Syndrome:

• Adjusted-dose VKA (target INR 2.5) preferred over DOAC therapy 1
• Anti-Xa measurement preferable for monitoring anticoagulation rather than aPTT 1

Pregnancy:

• Avoid vitamin K antagonists due to teratogenicity 1
• Use LMWH or unfractionated heparin throughout pregnancy 1

Renal Impairment:

• Adjust LMWH or fondaparinux dosing, or consider unfractionated heparin 1
• Monitor renal function and anti-Xa levels regularly 1

Additional Therapies

• Early ambulation with compression therapy once patient is stabilized 1
• Compression stockings to prevent post-thrombotic syndrome:
  • Initiate within 1 month of diagnosis
  • Continue for minimum of 1 year (ideally 2 years) 1
• Catheter-directed thrombolysis for cases with severe symptoms or extensive thrombosis 1, 5

Management of Complications

Bleeding on Anticoagulation:

• For major bleeding on warfarin: administer vitamin K and 4-factor prothrombin complex concentrate 1
• For bleeding on dabigatran: consider idarucizumab for reversal 1
• For bleeding on rivaroxaban/apixaban: consider andexanet alfa for reversal 1

Suspected Heparin-Induced Thrombocytopenia (HIT):

• Immediately discontinue heparin
• Switch to a direct thrombin inhibitor (lepirudin or argatroban) 1

Monitoring

• Clinical assessment within 1 week of diagnosis 1
• Follow-up ultrasound if symptoms worsen or fail to improve 1
• Regular monitoring for bleeding complications and therapeutic response 1
• For patients on warfarin: regular INR monitoring to maintain target 2.0-3.0 3