What are the treatment options for Deep Vein Thrombosis (DVT)?

From the Guidelines

For the treatment of deep vein thrombosis (DVT), direct oral anticoagulants (DOACs) such as rivaroxaban, apixaban, or edoxaban are preferred over vitamin K antagonist (VKA) therapy due to their efficacy and safety profile, as well as fewer monitoring requirements and food interactions. The standard treatment begins with either low molecular weight heparin (LMWH) such as enoxaparin at 1 mg/kg twice daily or fondaparinux at 5-10 mg once daily, overlapped with an oral anticoagulant 1. According to the American Society of Hematology 2020 guidelines, there is a conditional recommendation for the preference of direct oral anticoagulants over VKA for primary treatment of VTE 1.

Key Considerations

• Treatment typically continues for at least 3 months, but may be extended to 6-12 months or indefinitely depending on risk factors and whether the DVT was provoked by a temporary risk factor or unprovoked.
• During treatment, patients should stay active as tolerated, elevate the affected limb when resting, and avoid prolonged immobility.
• Anticoagulants work by interfering with the clotting cascade, preventing new clot formation while the body's natural fibrinolytic system dissolves the existing clot.
• Patients should be monitored for bleeding complications and advised to seek immediate medical attention for signs of pulmonary embolism like sudden shortness of breath or chest pain.

Specific Recommendations

• For VTE and no cancer, DOACs such as dabigatran, rivaroxaban, apixaban, or edoxaban are suggested over VKA therapy 1.
• For VTE and cancer, LMWH is suggested over VKA, dabigatran, rivaroxaban, apixaban, or edoxaban 1.
• The use of an international normalized ratio (INR) range of 2.0 to 3.0 is recommended over a lower INR range for patients with VTE who use a VKA for secondary prevention 1.

Quality of Life and Morbidity Considerations

• The treatment plan should prioritize minimizing the risk of recurrent VTE and pulmonary embolism, while also considering the risk of anticoagulant-related bleeding.
• Patients should be educated on the importance of adherence to their anticoagulation regimen and the need for regular follow-up appointments to monitor their condition and adjust their treatment plan as needed.

From the FDA Drug Label

XARELTO is a factor Xa inhibitor indicated: ... for treatment of deep vein thrombosis (DVT) ( 1.2) Treatment of DVT and/or PE: 15 mg orally twice daily with food for the first 21 days followed by 20 mg orally once daily with food for the remaining treatment ( 2.1) EINSTEIN Deep Vein Thrombosis and EINSTEIN Pulmonary Embolism Studies XARELTO for the treatment of DVT and/or PE was studied in EINSTEIN DVT [NCT00440193] and EINSTEIN PE [NCT00439777], multi-national, open-label, non-inferiority studies comparing XARELTO (at an initial dose of 15 mg twice daily with food for the first three weeks, followed by XARELTO 20 mg once daily with food) to enoxaparin 1 mg/kg twice daily for at least five days with VKA and then continued with VKA only after the target INR (2.0–3. 0) was reached.

The treatment for DVT is rivaroxaban (XARELTO), with a recommended dose of:

• 15 mg orally twice daily with food for the first 21 days
• Followed by 20 mg orally once daily with food for the remaining treatment 2 Alternatively, rivaroxaban (XARELTO) can be administered at an initial dose of 15 mg twice daily with food for the first three weeks, followed by 20 mg once daily with food, as studied in the EINSTEIN DVT trial 2.

From the Research

Treatment Options for DVT

• Anticoagulation is indicated to control symptoms, prevent progression, and reduce the risk of post-thrombotic syndrome and pulmonary embolism 3
• Anticoagulation may consist of a parenteral anticoagulant overlapped by warfarin or followed by a direct oral anticoagulant (DOAC) (dabigatran or edoxaban), or of a DOAC (apixaban or rivaroxaban) without initial parenteral therapy 3
• DOACs are the preferred treatment for DVT because they are at least as effective, safer, and more convenient than warfarin 3

Direct Oral Anticoagulants (DOACs)

• DOACs, such as apixaban, rivaroxaban, dabigatran, and edoxaban, are currently recommended as the first line of treatment for proximal DVT of the lower limbs 4
• Factors to consider when choosing the anticoagulant strategy include renal and liver function, underlying diseases such as cancer or the antiphospholipid syndrome, and patient preferences 4
• Apixaban treatment was associated with the most favorable safety profile of the NOACs, showing a statistically significantly reduced risk of major or clinically relevant non-major (CRNM) bleed compared with rivaroxaban, dabigatran, and edoxaban 5

Comparison of DOACs

• A systematic review and network meta-analysis compared the efficacy and safety of NOACs for the initial and long-term treatment of VTE, and found that there were no statistically significant differences between the NOACs with regard to the risk of VTE and VTE-related death 5
• Rivaroxaban is a reasonable alternative to standard therapy for the treatment of DVT and PE, and as extended thromboprophylaxis 6
• A Cochrane Review found that DOACs may be superior to conventional therapy in terms of safety (major bleeding), and are probably equivalent in terms of efficacy 7

Compression Therapy

• Elastic compression stockings (ECS) have been used for decades in patients with proximal DVT with the aim of counteracting the venous hypertension generated by the vascular disorder and reducing leg edema and to prevent the post-thrombotic syndrome 4