What is the treatment for phlebitis?

Treatment of Phlebitis

For superficial non-occlusive lower extremity phlebitis that is at least 5 cm in length, prophylactic anticoagulation with fondaparinux 2.5 mg daily or rivaroxaban 10 mg daily for 45 days is the recommended first-line treatment. 1, 2

Diagnosis and Assessment

• Ultrasound imaging is essential to confirm phlebitis diagnosis and exclude concurrent deep vein thrombosis (DVT), as approximately 25% of patients with superficial thrombophlebitis have underlying DVT 1, 2
• Comprehensive evaluation should assess the extent of thrombosis and proximity to the deep venous system 2

Treatment Based on Location and Severity

Extensive Lower Extremity Phlebitis (≥5 cm in length)

• First-line: Fondaparinux 2.5 mg subcutaneously once daily for 45 days 1, 2, 3
• Alternative: Rivaroxaban 10 mg orally daily for 45 days 1, 2
• Another alternative: Prophylactic-dose low molecular weight heparin (LMWH) for 45 days 1, 2, 3
• Anticoagulation reduces risk of progression to DVT (from 1.3% to 0.2%) and recurrent superficial vein thrombosis (from 1.6% to 0.3%) 1, 3

Phlebitis Near Saphenofemoral Junction

• If phlebitis is within 3 cm of the saphenofemoral junction, therapeutic dose anticoagulation for at least 3 months is recommended 1

Limited Phlebitis (<5 cm in length or below the knee)

• Consider repeat ultrasound in 7-10 days to assess for progression 1
• Consider anticoagulation if progression is found 1

Upper Extremity Phlebitis

• First-line treatment includes symptomatic measures (see below) 2
• Consider prophylactic anticoagulation only if there is symptomatic progression, progression on imaging, or if the clot is within 3 cm of the deep venous system 2

Symptomatic Treatment (for all types of phlebitis)

• Warm compresses to reduce inflammation and pain 1, 2, 4
• Non-steroidal anti-inflammatory drugs (NSAIDs) for pain control 1, 2, 4
• Elevation of the affected limb to reduce swelling 1, 2, 4
• Maintain mobility and avoid bed rest unless pain is severe 4
• Elastic compression (bandages or stockings) until elimination of the responsible varicose vein 4, 5

Catheter-Related Phlebitis

• If phlebitis is associated with a peripheral catheter that is no longer needed, remove the catheter 1, 2
• For prevention, intravenous catheters should be changed every 24-48 hours depending on venous flow and clinical parameters 4
• Topical nitroglycerin has shown effectiveness in reducing the inflammatory process in catheter-related phlebitis 6

Special Considerations

Cancer Patients

• Follow the same anticoagulation recommendations as non-cancer patients 1
• Closer monitoring is warranted due to higher risk of progression 2

Pregnant Patients

• LMWH is recommended over fondaparinux as fondaparinux crosses the placenta 1, 3
• Treatment should continue for the remainder of pregnancy and 6 weeks postpartum 3

Septic Phlebitis

• Prompt removal of any intravenous device 7
• Appropriate antibiotics based on culture results (most commonly targeting Staphylococcus aureus or Group A streptococcus) 7
• Consider surgical excision of the involved vein if clinical deterioration occurs or if septicemia persists after 24 hours despite conservative therapy 7

Monitoring and Follow-up

• Monitor for extension into the deep venous system, which would necessitate full therapeutic anticoagulation 1, 2
• For limited phlebitis being managed conservatively, repeat ultrasound in 7-10 days to assess for progression 1

Common Pitfalls to Avoid

• Failing to perform ultrasound to exclude concurrent deep vein thrombosis 1, 2, 8
• Inadequate duration of anticoagulation (45 days is recommended for extensive disease) 2, 3
• Unnecessary bed rest which may increase risk of DVT 4
• Using antibiotics when there is no documented infection 4