What is the recommended treatment dose for patients with deep vein thrombosis (DVT)?

Treatment Dose for Deep Vein Thrombosis

For acute DVT treatment, initiate rivaroxaban 15 mg twice daily with food for the first 21 days, then reduce to 20 mg once daily with food, or alternatively use apixaban 10 mg twice daily for 7 days followed by 5 mg twice daily. 1, 2, 3

Initial Treatment Phase (First 7-21 Days)

Direct Oral Anticoagulants (DOACs) - Preferred First-Line

Rivaroxaban regimen:

• 15 mg orally twice daily with food for 21 days 1, 2
• No parenteral anticoagulation required 2
• After 21 days, transition to 20 mg once daily with food 1, 2

Apixaban regimen:

• 10 mg orally twice daily for 7 days 1, 3
• No parenteral anticoagulation required 3
• After 7 days, transition to 5 mg twice daily 1, 3

Edoxaban regimen:

• Requires 5 days of parenteral anticoagulation (LMWH or unfractionated heparin) first 1
• Then 60 mg once daily (reduce to 30 mg once daily if creatinine clearance 30-50 mL/min or body weight <60 kg) 1

Low Molecular Weight Heparin (LMWH) - Alternative Option

Enoxaparin dosing:

• 1 mg/kg subcutaneously every 12 hours, OR 4
• 1.5 mg/kg subcutaneously once daily 4

Dalteparin dosing:

• 200 units/kg subcutaneously once daily 4

Tinzaparin dosing:

• 175 units/kg subcutaneously once daily 4

Unfractionated Heparin - For Renal Impairment

When creatinine clearance <30 mL/min:

• Bolus: 80 units/kg intravenously 4
• Continuous infusion: 18 units/kg/hour, adjusted to aPTT 4
• Preferred over LMWH due to hepatic elimination 4

Fondaparinux - Alternative Parenteral Option

Weight-based dosing:

• <50 kg: 5 mg subcutaneously once daily 4
• 50-100 kg: 7.5 mg subcutaneously once daily 4

• 100 kg: 10 mg subcutaneously once daily 4

Maintenance Treatment Phase (After Initial 7-21 Days)

Standard maintenance doses:

• Rivaroxaban: 20 mg once daily with food 1, 2
• Apixaban: 5 mg twice daily 1, 3
• Edoxaban: 60 mg once daily 1
• Warfarin: Adjust to INR 2.0-3.0 1, 4

Duration of treatment:

• Minimum 3 months for provoked DVT with transient risk factors 1
• Indefinite anticoagulation for unprovoked DVT or persistent risk factors 1

Special Population Considerations

Cancer-Associated DVT

Preferred agents (Grade 1A):

• LMWH: Enoxaparin 1 mg/kg every 12 hours or 1.5 mg/kg once daily 1
• DOACs: Rivaroxaban or apixaban (avoid in high gastrointestinal/genitourinary bleeding risk) 1
• Edoxaban after 5 days of parenteral anticoagulation 1

Critical caveat: DOACs carry higher gastrointestinal bleeding risk than LMWH in patients with gastrointestinal malignancies 5

Renal Impairment

Creatinine clearance ≥30 mL/min:

• All DOACs and LMWH are acceptable 1

Creatinine clearance <30 mL/min:

• Use unfractionated heparin (hepatic elimination) 4
• Avoid or significantly reduce DOAC doses 1
• Edoxaban: reduce to 30 mg once daily 1

Pregnancy

Avoid all DOACs and warfarin:

• Use LMWH exclusively (does not cross placenta) 4
• Continue throughout pregnancy and 6 weeks postpartum 6

Key Dosing Pitfalls to Avoid

Common errors:

• Starting rivaroxaban at 20 mg twice daily instead of 15 mg twice daily for the first 21 days 2
• Using apixaban 5 mg twice daily from day 1 instead of 10 mg twice daily for first 7 days 3
• Starting edoxaban without 5 days of parenteral anticoagulation first 1
• Failing to take rivaroxaban with food (reduces absorption) 2
• Using therapeutic-dose LMWH in severe renal impairment (creatinine clearance <30 mL/min) 4

Monitoring Requirements

DOACs:

• No routine laboratory monitoring required 4
• Check renal function at baseline and periodically 1

Warfarin:

• Target INR 2.0-3.0 1, 4
• Check INR frequently during initiation, then monthly when stable 1

LMWH:

• No routine anti-Xa monitoring in most patients 4
• Consider monitoring in extremes of body weight, renal impairment, or pregnancy 4