What is the management of Deep Vein Thrombosis (DVT)?

Management of Deep Vein Thrombosis (DVT)

For patients with deep vein thrombosis (DVT), the American Society of Hematology recommends home treatment over hospital treatment for uncomplicated cases, with direct oral anticoagulants (DOACs) as the preferred initial therapy over vitamin K antagonists for primary treatment. 1

Initial Management and Setting of Care

• For uncomplicated DVT, home treatment is preferred over hospital treatment 1

  • Exception: Patients who require hospitalization for other conditions, have limited home support, cannot afford medications, have poor compliance history, limb-threatening DVT, high bleeding risk, or require IV analgesics

• For PE with low risk of complications, home treatment may also be considered 1

Anticoagulation Therapy

Initial Anticoagulation Options

1. Direct Oral Anticoagulants (DOACs) - First-line therapy

   • Apixaban or rivaroxaban without initial parenteral therapy
   • Dabigatran or edoxaban following 5 days of parenteral anticoagulation 2
   • DOACs are preferred due to being at least as effective, safer, and more convenient than warfarin 2, 3

2. Low Molecular Weight Heparin (LMWH)

   • Enoxaparin: 1 mg/kg subcutaneously twice daily or 1.5 mg/kg once daily 4
   • Dalteparin: 200 IU/kg once daily or 100 IU/kg twice daily 1
   • Tinzaparin: 175 anti-Xa IU/kg once daily 1

3. Unfractionated Heparin (UFH)

   • Initial bolus of 80 U/kg followed by continuous IV infusion at 18 U/kg/h
   • Adjust dose to target aPTT corresponding to plasma heparin levels of 0.3-0.7 IU/mL anti-factor Xa activity 1

4. Fondaparinux

   • 5 mg daily for patients <50 kg
   • 7.5 mg daily for patients 50-100 kg
   • 10 mg daily for patients >100 kg 1

Duration of Primary Treatment

• For all DVT patients: 3-6 months of anticoagulation is recommended for primary treatment 1
• Shorter course (3-6 months) is preferred over longer course (6-12 months) for primary treatment regardless of whether DVT was:
  • Provoked by transient risk factors
  • Provoked by chronic risk factors
  • Unprovoked 1

Long-Term Anticoagulation (Secondary Prevention)

Duration depends on risk factors:

1. First episode with major reversible risk factor (surgery, trauma):

   • Anticoagulation can be safely stopped after 3 months 1

2. Recurrent DVT or unprovoked DVT:

   • Consider indefinite anticoagulation with periodic reassessment 1
   • Strong recommendation for indefinite anticoagulation for patients with recurrent unprovoked VTE 1

3. Cancer-associated DVT:

   • LMWH monotherapy for at least 3-6 months or as long as cancer/chemotherapy is ongoing 1
   • Recent evidence shows edoxaban or rivaroxaban may be used if patients prefer not to have daily LMWH injections 2
   • Caution: Higher risk of GI bleeding with DOACs in patients with GI cancer 2

Special Considerations

Renal Dysfunction

• DOACs may require dose reduction or avoidance in patients with renal dysfunction 2
• For severe renal failure, vitamin K antagonists may be preferred 3

Pregnancy

• DOACs should be avoided in pregnancy 2
• LMWH is typically preferred 5

Massive/Submassive DVT

• For PE with hemodynamic compromise, thrombolytic therapy is strongly recommended 1
• For proximal DVT with significant preexisting cardiopulmonary disease, anticoagulation alone is suggested rather than anticoagulation plus IVC filter 1

Prevention of Post-Thrombotic Syndrome

• Compression stockings (30-40 mmHg, knee-high) should be prescribed within 1 month of diagnosis and continued for at least 1-2 years 5

Monitoring and Follow-up

• For patients on warfarin, target INR of 2.0-3.0 1
• Monitor renal function in patients on DOACs or LMWH 5
• Annual reassessment of the need for continued anticoagulation for those on indefinite therapy 5
• Regular assessment for post-thrombotic syndrome 5

Common Pitfalls to Avoid

• Delaying anticoagulation while awaiting infection workup can lead to adverse outcomes 5
• Unnecessary hospitalization for uncomplicated DVT increases costs without improving outcomes
• Using DOACs in patients with severe renal failure (CrCl <15 mL/min) where they lack official indication 5
• Failure to consider cancer screening in patients with unprovoked DVT
• Neglecting to prescribe compression therapy to prevent post-thrombotic syndrome