Treatment for Acute Deep Vein Thrombosis (DVT)
For patients with acute DVT, direct oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, or rivaroxaban are recommended over vitamin K antagonists (VKAs) as first-line treatment. 1
Initial Management
- For patients with acute DVT treated with VKA therapy, initial treatment with parenteral anticoagulation (LMWH, fondaparinux, IV UFH, or SC UFH) is recommended 1
- Low-molecular-weight heparin (LMWH) or fondaparinux is preferred over intravenous unfractionated heparin (IV UFH) and over subcutaneous UFH 1, 2
- For patients with acute DVT who are candidates for VKA therapy, early initiation of VKA (same day as parenteral therapy) is recommended with continuation of parenteral anticoagulation for a minimum of 5 days and until the INR is ≥2.0 for at least 24 hours 1
- For patients with DVT in the setting of cancer, oral factor Xa inhibitors (apixaban, edoxaban, rivaroxaban) are recommended over LMWH for initial and treatment phases 1
- Rivaroxaban can be used as monotherapy without initial parenteral anticoagulation (15 mg twice daily for 21 days and then 20 mg once daily) 2
Treatment Setting
- For patients with acute DVT of the leg whose home circumstances are adequate, initial treatment at home is recommended over treatment in hospital 1
- Early ambulation is suggested over initial bed rest for patients with acute DVT 1
- Home treatment is conditional on:
- Well-maintained living conditions
- Strong support from family or friends
- Phone access
- Ability to quickly return to hospital if deterioration occurs 1
Treatment Duration
- A minimum 3-month treatment phase of anticoagulation is recommended for patients with objectively confirmed DVT 1, 3
- For patients with DVT secondary to a major transient risk factor, extended anticoagulation beyond 3 months is not recommended 1
- For patients with DVT secondary to a minor transient risk factor, extended anticoagulation is generally not suggested 1
- For patients with unprovoked DVT or DVT provoked by persistent risk factors, extended anticoagulation with a DOAC is recommended 1
- For patients with DVT and active cancer who do not have high bleeding risk, extended anticoagulant therapy (no scheduled stop date) is recommended 1
Special Considerations
- For patients with isolated distal DVT without severe symptoms or risk factors for extension, serial imaging of deep veins for 2 weeks is suggested over initial anticoagulation 1
- For patients with isolated distal DVT with severe symptoms or risk factors for extension, initial anticoagulation is suggested over serial imaging 1
- For patients with acute proximal DVT, anticoagulant therapy alone is generally suggested over catheter-directed thrombolysis 1
- For patients with acute DVT, an inferior vena cava (IVC) filter is not recommended in addition to anticoagulants 1
- For patients with acute proximal DVT and contraindication to anticoagulation, an IVC filter is recommended 1, 2
- For prevention of post-thrombotic syndrome, elastic compression stockings are suggested 4
Dosing of Anticoagulants
- For enoxaparin (LMWH): 1 mg/kg every 12 hours subcutaneously or 1.5 mg/kg once daily subcutaneously 5
- When using LMWH, once-daily administration is suggested over twice-daily administration when using the same total daily dose 1
- For patients treated with VKA, a therapeutic INR range of 2.0-3.0 (target INR 2.5) is recommended 1
Common Pitfalls and Caveats
- Avoid using LMWH in patients with severe renal impairment (CrCl <30 mL/min) due to risk of drug accumulation 2
- Fondaparinux is contraindicated in patients with CrCl <30 mL/min 2
- When transitioning from parenteral anticoagulation to VKA, continue parenteral therapy until the INR is therapeutic (≥2.0) for at least 24 hours 1
- High-intensity VKA therapy (INR 3.1-4.0) and low-intensity therapy (INR 1.5-1.9) should be avoided compared to standard intensity (INR 2.0-3.0) 4
- Thrombolytic therapy should be reserved for specific cases and is not routinely recommended for most DVT patients 6, 7