What is the treatment plan for acute Deep Vein Thrombosis (DVT) in the left upper extremity (LUE)?

Treatment Plan for Acute Left Upper Extremity DVT

For acute left upper extremity DVT, initiate therapeutic anticoagulation immediately with a direct oral anticoagulant (DOAC) such as apixaban, rivaroxaban, edoxaban, or dabigatran as first-line therapy, and continue treatment for a minimum of 3 months. 1

Initial Anticoagulation Strategy

Start a DOAC immediately rather than vitamin K antagonists (VKAs), as DOACs are the preferred first-line agents for acute DVT treatment. 1 The specific DOACs recommended include:

• Apixaban
• Rivaroxaban
• Edoxaban
• Dabigatran 1

If DOACs are contraindicated or unavailable, use parenteral anticoagulation with low-molecular-weight heparin (LMWH) or fondaparinux, which are preferred over unfractionated heparin (either IV or subcutaneous). 2, 1

LMWH Dosing Options

• Enoxaparin 1.5 mg/kg subcutaneously once daily (preferred for outpatient treatment) 2
• Enoxaparin 1 mg/kg subcutaneously twice daily 2
• Dalteparin 200 U/kg subcutaneously once daily 2

Fondaparinux Dosing (weight-based)

• <50 kg: 5 mg once daily
• 50-100 kg: 7.5 mg once daily

• 100 kg: 10 mg once daily 2

Catheter-Related Considerations

If the upper extremity DVT is catheter-related, do not remove the catheter as long as it remains functional and clinically necessary. 2 Continue anticoagulation for the entire duration the catheter remains in place. 2

Treatment Duration

Minimum Duration

All patients require at least 3 months of therapeutic anticoagulation. 2, 1

Extended Therapy Decision Algorithm

For provoked DVT (catheter-related or other transient risk factor):

• Stop anticoagulation after 3 months 1
• Extended therapy beyond 3 months is not recommended 1

For unprovoked DVT or persistent risk factors:

• Continue extended anticoagulation with a DOAC (no scheduled stop date) if bleeding risk is low to moderate 1
• Reassess periodically for benefit-risk balance 1

For cancer-associated DVT:

• Use oral factor Xa inhibitors (apixaban, edoxaban, or rivaroxaban) over LMWH 1
• Continue extended anticoagulation as long as cancer remains active 1

Bridging to VKA (If DOAC Not Used)

If using warfarin instead of a DOAC:

• Start warfarin on day 1 simultaneously with parenteral anticoagulation 1
• Continue parenteral therapy (LMWH/fondaparinux) for minimum 5 days AND until INR ≥2.0 for at least 24 hours 1
• Target INR range: 2.0-3.0 (target 2.5) 1

Monitoring Requirements

For DOACs:

• No routine coagulation monitoring required 3
• Assess renal function periodically 3

For VKAs:

• Regular INR monitoring targeting 2.0-3.0 3

Common Pitfalls to Avoid

• Do not delay anticoagulation while awaiting imaging if clinical suspicion is high - treat empirically 1
• Do not stop parenteral anticoagulation prematurely when bridging to warfarin - must overlap until INR therapeutic for 24 hours 1
• Do not automatically remove functional central venous catheters - they can remain in place with continued anticoagulation 2
• Caution with LMWH if creatinine clearance <30 mL/min due to drug accumulation 2