What is the treatment for thrombosis?

Treatment of Thrombosis

The initial treatment for thrombosis should include parenteral anticoagulation with low-molecular-weight heparin (LMWH), fondaparinux, intravenous unfractionated heparin (IV UFH), or subcutaneous unfractionated heparin (SC UFH), with LMWH being the preferred agent due to superior efficacy and safety profile. 1, 2, 3

Initial Management

• For acute deep vein thrombosis (DVT), parenteral anticoagulation should be initiated immediately upon diagnosis 1, 2
• LMWH is preferred over unfractionated heparin for initial treatment due to reduced mortality and major bleeding risk 2, 3
• For patients with high clinical suspicion of thrombosis, treatment with parenteral anticoagulants should be initiated while awaiting diagnostic test results 1, 2
• Outpatient treatment with LMWH is appropriate for carefully selected patients without significant comorbidities or high bleeding risk 2, 3
• Oral anticoagulant therapy should be started within 24 hours of initiating parenteral anticoagulation 2

Anticoagulation Selection

• For DVT without cancer, direct oral anticoagulants (DOACs) are recommended over vitamin K antagonists (VKAs) such as warfarin due to superior efficacy and safety profile 2, 3
• For patients with DVT and active cancer, LMWH is suggested over VKA therapy or DOACs 2, 1
• For patients not eligible for DOACs, VKA therapy (warfarin) is suggested over LMWH for long-term treatment 2
• When using VKA therapy, continue parenteral anticoagulation for a minimum of 5 days and until INR is ≥2.0 for at least 24 hours 3, 4

Duration of Anticoagulation

• For DVT provoked by surgery or other transient risk factors, 3 months of anticoagulation is recommended 1, 2, 3
• For unprovoked DVT, a minimum of 3 months of anticoagulation is recommended, with evaluation for extended therapy after this period 2, 3
• For unprovoked proximal DVT with low or moderate bleeding risk, extended anticoagulation therapy is suggested 1, 2
• For DVT associated with active cancer, extended anticoagulation therapy (no scheduled stop date) is recommended 1, 2

Special Considerations

Coronary Artery Thrombosis

• Coronary artery thrombosis with actual or impending occlusion should be treated with thrombolytic therapy or mechanical restoration of blood flow via cardiac catheterization 1
• Thrombolytic agents should be administered together with low-dose aspirin and low-dose heparin with careful monitoring for bleeding 1

Intracardiac Thrombus

• Patients with evident intracardiac thrombus should be treated with systemic anticoagulation for at least 3 months 1
• Thrombi causing significant hemodynamic abnormalities or at high risk of embolization should receive thrombolytic therapy or surgical thrombectomy 1

Heparin-Induced Thrombocytopenia (HIT)

• For patients who develop HIT with thrombosis, all forms of heparin should be discontinued immediately 1
• Non-heparin anticoagulants should be used instead for these patients 1

Adjunctive Therapies

• Inferior vena cava filters are not recommended for patients with DVT who can be treated with anticoagulants 2, 3
• Compression stockings are no longer routinely recommended to prevent post-thrombotic syndrome 2
• Early ambulation is suggested over initial bed rest for patients with acute DVT 3
• For patients with recurrent venous thromboembolism on non-LMWH anticoagulants, switching to LMWH is suggested 2, 3

Monitoring and Follow-up

• For patients on warfarin, the dose should be adjusted to maintain a target INR of 2.5 (range 2.0-3.0) for most indications 4
• Regular assessment of bleeding risk should be performed at follow-up visits 3
• For patients with unprovoked DVT who complete the initial treatment period, reassessment for extended therapy is necessary based on individual risk factors for recurrence versus bleeding 2, 3