What are the most commonly used anticoagulants for Deep Vein Thrombosis (DVT)?

Most Commonly Used Anticoagulants for DVT

For acute DVT treatment, the most commonly used anticoagulants are direct oral anticoagulants (DOACs)—specifically apixaban, rivaroxaban, edoxaban, or dabigatran—which are now preferred over traditional vitamin K antagonists (warfarin) for the initial 3-month treatment phase. 1

Initial Treatment Phase (First 5-7 Days)

For patients starting anticoagulation, the following parenteral agents are most commonly used initially when transitioning to warfarin 1:

• Low-molecular-weight heparin (LMWH): Preferred initial parenteral agent 1

  • Enoxaparin: 1 mg/kg twice daily or 1.5 mg/kg once daily 1
  • Dalteparin: 200 IU/kg once daily or 100 IU/kg twice daily 1
  • Tinzaparin: 175 anti-Xa IU/kg once daily 1

• Fondaparinux: Weight-based subcutaneous dosing 1, 2

  • 5 mg for patients <50 kg
  • 7.5 mg for patients 50-100 kg
  • 10 mg for patients >100 kg

• Unfractionated heparin (UFH): Less preferred, reserved for specific situations like severe renal impairment 1

  • Initial bolus: 80 U/kg IV, followed by 18 U/kg/hour infusion 1

Important distinction: DOACs like rivaroxaban and apixaban can be started immediately without parenteral lead-in, while dabigatran and edoxaban require 5-7 days of parenteral anticoagulation first 1.

Long-Term Treatment Phase (First 3 Months)

The CHEST guidelines strongly recommend DOACs over warfarin for non-cancer patients 1:

• Apixaban: 10 mg twice daily for 7 days, then 5 mg twice daily 1, 3
• Rivaroxaban: 15 mg twice daily for 21 days, then 20 mg once daily 1
• Edoxaban: Requires 5-7 days parenteral anticoagulation first, then 60 mg once daily 1
• Dabigatran: Requires 5-7 days parenteral anticoagulation first, then 150 mg twice daily 1

For patients who cannot receive DOACs, warfarin remains an option with target INR 2.0-3.0, overlapped with parenteral anticoagulation for minimum 5 days and until INR ≥2.0 for at least 24 hours 1.

Special Population: Cancer-Associated DVT

For cancer patients, the treatment hierarchy differs significantly 1:

• First-line (2024 update): Oral Factor Xa inhibitors (apixaban, edoxaban, rivaroxaban) are now preferred over LMWH 1
• Important caveat: For patients with luminal GI malignancies, apixaban or LMWH may be preferred due to lower GI bleeding risk with these agents compared to rivaroxaban or edoxaban 1
• Alternative: LMWH monotherapy remains acceptable 1
  • Dalteparin: 200 IU/kg daily for first month, then 150 IU/kg daily 1
  • Continue for at least 3-6 months or as long as cancer is active 1

Key Clinical Considerations

Heparin-induced thrombocytopenia (HIT): Use direct thrombin inhibitors (argatroban, lepirudin) instead of heparin products 1.

Outpatient vs. inpatient treatment: Most DVT patients can be treated as outpatients with LMWH, fondaparinux, or DOACs if home circumstances are adequate 1.

Monitoring requirements: DOACs do not require routine laboratory monitoring, a major advantage over warfarin which requires frequent INR checks 1. LMWH does not require routine anti-factor Xa monitoring 1.

Common Pitfall to Avoid

Do not use dabigatran or edoxaban as monotherapy for acute DVT—these agents require 5-7 days of parenteral anticoagulation before initiation, unlike rivaroxaban and apixaban which can be used from day one 1. This is a critical distinction that affects treatment planning and patient convenience.