Treatment of Venous Thrombosis (DVT and PE)
For most patients with venous thromboembolism (VTE), direct oral anticoagulants (DOACs) are the recommended first-line treatment over vitamin K antagonists due to their favorable efficacy and safety profile. 1
Initial Management
- For patients with acute DVT or PE, initial parenteral anticoagulation with low-molecular-weight heparin (LMWH), unfractionated heparin (UFH), or fondaparinux is recommended, followed by oral anticoagulation 1, 2
- Home treatment is preferred over hospitalization for patients with uncomplicated DVT when appropriate home circumstances exist 1, 2
- For patients with PE and hemodynamic compromise (systolic BP <90 mmHg or a decrease ≥40 mmHg), thrombolytic therapy followed by anticoagulation is strongly recommended over anticoagulation alone 1, 3
- For patients with submassive PE (right ventricular dysfunction without hemodynamic compromise), anticoagulation alone is suggested over routine thrombolysis 3
Anticoagulant Selection
- DOACs (rivaroxaban, apixaban, dabigatran, edoxaban) are preferred over vitamin K antagonists (VKAs) for most patients with VTE 1, 2
- No specific DOAC is recommended over another; selection should be individualized based on patient factors such as renal function, concomitant medications, and dosing preferences 1
- If dabigatran or edoxaban is selected, parenteral anticoagulation must be administered concomitantly for at least 5 days 4
- For patients with active cancer, LMWH is preferred over VKAs or DOACs 1, 2
- Enoxaparin (LMWH) has been shown to be as effective as unfractionated heparin in reducing the risk of recurrent VTE 5
Special Considerations
- For patients with limb-threatening DVT (phlegmasia cerulea dolens) or younger patients with iliac/common femoral vein DVT at low bleeding risk, thrombolysis may be considered 3
- Catheter-directed thrombolysis is suggested over systemic thrombolysis for extensive DVT when thrombolysis is deemed appropriate 3
- Inferior vena cava (IVC) filters are not routinely recommended in addition to anticoagulation for patients with DVT or PE 3
- IVC filters may be considered only for patients with a contraindication to anticoagulation, with retrieval as soon as the patient is able to receive anticoagulation 3
Treatment Duration
- For primary treatment of DVT/PE provoked by a transient risk factor, a shorter course of anticoagulation (3-6 months) is suggested over a longer course (6-12 months) 3
- For DVT/PE provoked by a chronic risk factor, indefinite antithrombotic therapy is suggested over stopping anticoagulation after the primary treatment phase 3
- For unprovoked DVT/PE, extended therapy may be appropriate after completion of the primary treatment phase, especially for patients with low or moderate bleeding risk 1, 2
- Routine use of prognostic scores, D-dimer testing, or ultrasound to detect residual vein thrombosis is not recommended to guide the duration of anticoagulation 3
Monitoring and Follow-up
- Regular assessment of renal function is important when using DOACs, as dosing may need adjustment 1, 2
- For patients receiving extended anticoagulation therapy, reassessment should occur at periodic intervals (e.g., annually) 1, 2
- Patients should be monitored for signs of bleeding complications and recurrent thrombosis 2
Common Pitfalls and Considerations
- Premature discontinuation of anticoagulation increases the risk of thrombotic events 6
- Patients with cancer have both a higher rate of VTE recurrences and a higher anticoagulation-associated hemorrhagic risk compared with non-cancer patients 1, 2
- DOACs have drug interactions with medications metabolized through CYP3A4 enzyme or P-glycoprotein that may affect their efficacy 2
- For patients with severe renal insufficiency, high bleeding risk, hemodynamic instability, or morbid obesity, unfractionated heparin may be preferred over LMWH 4
- Dabigatran is contraindicated in patients with mechanical prosthetic heart valves 6