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Anticoagulation for deep venous thrombosis (DVT)

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Anticoagulation is the main treatment approach in venous thromboembolism treatment.

  • patients with proximal DVT/PE should be anticoagulated for at least 3 months


  • patients with isolated distal DVT
    • at high-risk of recurrence – anticoagulated as for proximal DVT
    • at low-risk of recurrence - shorter treatment (4–6 weeks), even at lower anticoagulant doses, or ultrasound surveillance may be considered (1,2)

Current guidelines recommend a two phase anticoagulation treatment:

  • initial phase of intensified anticoagulation followed by anticoagulation therapy for 3 months
  • extended phase of anticoagulation
    • beyond first 3-6 months
    • should consider between the risk for VTE recurrence without long term anticoagulants vs bleeding with anticoagulants (3)

NICE suggest (4):

Anticoagulation treatment for proximal DVT or PE

  • measure baseline full blood count, renal and hepatic function, PT and APTT but start anticoagulation before results available. Review and if necessary act on results within 24 hours
  • offer anticoagulation for at least 3 months. Take into account contraindications, comorbidities and the person’s preferences
  • after 3 months (3 to 6 months for active cancer) assess and discuss the benefits and risks of continuing, stopping or changing the anticoagulant with the person. See long-term anticoagulation for secondary prevention(linked item)

Anticagulatant considerations considered in terms of:

  • No renal impairment, active cancer, antiphospholipid syndrome or haemodynamic instability
    • offer apixaban or rivaroxaban
    • if neither suitable, offer one of:
      • LMWH for at least 5 days followed by dabigatran or edoxaban
      • LMWH and a VKA for at least 5 days, or until INR at least 2.0 on 2 consecutive readings, then a VKA alone

  • Renal impairment (CrCl estimated using the Cockcroft and Gault formula; see the BNF)
    • CrCl 15 to 50 ml/min, offer one of:
      • apixaban
      • rivaroxaban
      • LMWH for at least 5 days then
        • edoxaban or
        • dabigatran if CrCl >= 30 ml/min
      • LMWH or UFH and a VKA for at least 5 days, or until INR at least 2.0 on 2 consecutive readings, then a VKA alone

    • CrCl < 15 ml/min, offer one of:
      • LMWH
      • UFH
      • LMWH or UFH and a VKA for at least 5 days, or until INR at least 2.0 on 2 consecutive readings, then a VKA alone
    • Note cautions and requirements for dose adjustments and monitoring in SPCs. Follow local protocols, or specialist or MDT advice
  • Active cancer (receiving antimitotic treatment, diagnosed in past 6 months, recurrent, metastatic or inoperable
    • Consider a DOAC
    • if a DOAC is not suitable, consider one of:
      • LMWH
      • LMWH and a VKA for at least 5 days or until INR at least 2.0 on 2 consecutive readings, then a VKA alone
    • Offer anticoagulation for 3 to 6 months. Take into account tumour site, drug interactions including cancer drugs, and bleeding risk
  • Antiphospholipid syndrome (triple positive, established diagnosis)
    • Offer LMWH and a VKA for at least 5 days or until INR at least 2.0 on 2 consecutive readings, then a VKA alone

 

Notes (4):

  • PE with haemodynamic instability - Offer continuous UFH infusion and consider thrombolytic therapy
  • Body weight
    • if body weight <50 kg or >120 kg consider anticoagulant with monitoring of therapeutic levels.
      Note cautions and requirements for dose adjustments and monitoring in SPCs. Follow local protocols, or specialist or MDT advice
  • INR monitoring
    • Do not routinely offer self-management or self-monitoring of INR
  • Prescribing in renal impairment and active cancer
    • some LMWHs are off label in renal impairment, and most anticoagulants are off label in active cancer
  • Follow GMC guidance on prescribing unlicensed medicines
  • Treatment failure
    • If anticoagulation treatment fails:
      • check adherence
      • address other sources of hypercoagulability
      • increase the dose or change to an anticoagulant with a different mode of action

Reference:


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