Deep vein thrombosis treatment approach
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Resident Survival Guide |
Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] ; Kashish Goel, M.D.; Assistant Editor(s)-In-Chief: Justine Cadet
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Initial Treatment
Shown below is an algorithm depicting the initial choice of treatment among patients with DVT. Note that the treatment of DVT with parental anticoagulation should be initiated in case of intermediate or high suspicion of suspected DVT even before the diagnostic confirmatory tests are complete. The choice of parental anticoagulation include: low molecular weight heparin (LMWH), fondaparinux, IV unfractionated heparin (UFH) and SC-UFH; however, the administration of LMWH (once daily rather than twice) and fondaparinux is recommended over IV-UFH and SCUFH. Parental anticoagulation therapy should be administered for at least 5 days and until the INR is equal or more than 2 for more than 24 hours.[1]
| Is the DVT proximal or distal? | |||||||||||||||||||||||||||||||||||
| Proximal DVT | Isolated distal DVT | ||||||||||||||||||||||||||||||||||
| Are there any contraindications to anticoagulation? | Does the patient have severe symptoms OR risk factors for the extension of the thrombus? | ||||||||||||||||||||||||||||||||||
| No | Yes | Yes | No | ||||||||||||||||||||||||||||||||
| Begin initial anticoagulation treatment Begin oral anticoagulant as an overlap therapy for the long term treatment | IVC filter Begin conventional course of anticoagulation if the risk of bleeding subsides | Begin initial anticoagulation treatment (if there are no contraindications) Begin oral anticoagulant as an overlap therapy for the long term treatment | Perform serial imaging for 2 weeks | ||||||||||||||||||||||||||||||||
| Does the repeated US demonstrate any extension of the thrombus (with or without extension to the proximal veins) | |||||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||||
| Begin initial anticoagulation treatment (if there are no contraindications) Begin oral anticoagulant as an overlap therapy for the long term treatment | No anticoagulation therapy | ||||||||||||||||||||||||||||||||||
Initial Anticoagulation Choices
❑ SC low molecular weight heparin (1st line)
- ❑ Enoxaparin 1.0 mg/kg every 12 hours OR 1.5 mg/kg once daily
- ❑ Tinzaparin 175 U/kg once daily
❑ SC fondaparinux (1st line)
- ❑ 5 mg once daily (if body weight <50 kg)
- ❑ 7.5 mg once daily (if body weight <50-100 kg)
- ❑ 10 mg once daily (if body weight >100 kg)
- ❑ 80 U/kg as bolus, followed by 18 U/kg/h, OR
- ❑ 70 U/kg as bolus, followed by 15 U/kg/h for stroke or cardiac patients[2]
- ❑ Adjust the dosages according to the aPTT
- ❑ 333 U/kg as bolus, followed by 250 U/kg[2]
ACCP 2012 Guidelines: Recommendations for Initial Approach in Patients with Acute DVT of the Leg (DO NOT EDIT)[3]
| Grade 1 |
| "1. In patients with acute DVT of the leg treated with vitamin K antagonist (VKA) therapy, we recommend initial treatment with parenteral anticoagulation (low-molecular-weight heparin [LMWH], fondaparinux, IV unfractionated heparin [UFH], or subcutaneous [SC] UFH) over no such initial treatment. (Level of evidence B)" |
| Grade 2 |
| "1. In patients with a high clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment while awaiting the results of diagnostic tests. (Level of evidence C)" |
| "2. In patients with an intermediate clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment if the results of diagnostic tests are expected to be delayed for more than 4 h (Level of evidence C)." |
| "3. In patients with a low clinical suspicion of acute VTE, we suggest not treating with parenteral anticoagulants while awaiting the results of diagnostic tests, provided test results are expected within 24 h (Level of evidence C)." |
References
- ↑ {{http://www.wikidoc.org//index.php/Template:Cite_journal{cite journal| author=Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ et al.| title=Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e419S-94S | pmid=22315268 | doi=10.1378/chest.11-2301 | pmc=PMC3278049 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315268 }}
- ↑ 2.0 2.1 Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ; et al. (2012). "Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e152S–84S. doi:10.1378/chest.11-2295. PMC 3278055. PMID 22315259.
- ↑ Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ (2012). "Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): 7S–47S. doi:10.1378/chest.1412S3. PMID 22315257. Unknown parameter
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