Treatment for Thrombophlebitis
The recommended treatment for thrombophlebitis depends on whether it is superficial or deep, with low-molecular-weight heparin (LMWH) being the preferred initial treatment for deep venous thrombosis (DVT), while superficial thrombophlebitis may be managed with compression stockings, NSAIDs, and anticoagulation if extensive. 1
Initial Assessment and Classification
- Determine whether the thrombophlebitis is superficial or deep through clinical examination and appropriate imaging (duplex ultrasound) 2
- Evaluate for extension into deep veins, as this significantly impacts treatment decisions 1
- Assess for risk factors and underlying causes (cancer, thrombophilia, etc.) 1
Treatment of Deep Vein Thrombosis (DVT)
Initial Anticoagulation
- LMWH is recommended over unfractionated heparin (UFH) for initial treatment of DVT due to superior efficacy and reduced mortality risk 1
- Recommended dosing for enoxaparin is 1.0 mg/kg twice daily or 1.5 mg/kg once daily 3
- Once-daily administration of LMWH is suggested over twice-daily when using the same total daily dose 1
- For patients with renal impairment or those who may need thrombolytic therapy, UFH may be preferred 1
Transition to Long-Term Anticoagulation
- Begin vitamin K antagonist (VKA) therapy on the same day as parenteral therapy 1
- Continue parenteral anticoagulation for at least 5 days and until INR is ≥2.0 for at least 24 hours 1
- For non-cancer patients, direct oral anticoagulants (dabigatran, rivaroxaban, apixaban, or edoxaban) are suggested over VKA therapy 1
- For cancer-associated thrombosis, LMWH is suggested over VKA or direct oral anticoagulants 1
Duration of Treatment
- For DVT provoked by surgery: 3 months of anticoagulation 1
- For DVT provoked by non-surgical transient risk factor: 3 months of anticoagulation 1
- For unprovoked DVT: consider extended therapy (no scheduled stop date) if bleeding risk is low or moderate; 3 months if bleeding risk is high 1
- For cancer-associated DVT: extended therapy is recommended 1
Treatment of Superficial Thrombophlebitis
- For limited superficial thrombophlebitis: compression stockings and NSAIDs 4, 5
- For extensive superficial vein thrombosis: prophylactic-dose fondaparinux or LMWH is suggested over no anticoagulation 1
- Consider surgical treatment (ligation with or without stripping) for superficial thrombophlebitis associated with varicose veins 4, 5
- Monitor for extension into deep veins, which would require full anticoagulation 5
Home vs. Hospital Treatment
- Initial treatment at home is recommended for patients with DVT whose home circumstances are adequate 1
- Requirements for home treatment include: well-maintained living conditions, strong support system, phone access, ability to return to hospital if needed, and patient feeling well enough 1
Prevention of Post-Thrombotic Syndrome
- Compression stockings should be used to prevent post-thrombotic syndrome 1
- Begin compression therapy within 1 month of diagnosis of proximal DVT 1
- Continue compression therapy for a minimum of 1 year after diagnosis 1
Special Considerations
- Avoid vitamin K antagonists in pregnant women due to risk of embryopathy and fetal bleeding 1
- Consider catheter-directed thrombolysis for patients with extensive proximal DVT who place high value on preventing post-thrombotic syndrome 1
- IVC filters are not recommended in addition to anticoagulants but may be used when anticoagulation is contraindicated 1