see also:

• Rx of venous thrombosis (DVT/PE) and superficial thrombophlebitis - American College of Chest Physicians guidelines 2012
• deep venous thrombosis (DVT)
• Mx of suspected DVT
• upper limb DVT
• Mx of PE
• guidelines on starting anticoagulation and warfarin Rx
• AFTB lectures - venous thromboembolism
• DVT prophylaxis
• thrombophlebitis

• re-assess patient for clinical evidence of pulmonary embolism and if PE suspected, Mx as investigation of suspected pulmonary embolism, if PE confirmed then see Mx of PE.
• support stockings (eg. TED stockings)

• discuss with O&G reg., remember warfarin C/I in pregnancy due to teratogenic effects.

• then apixaban Rx
  • consider admission under general medicine unit if high risk, otherwise admit to HITH
• if involving iliac vessels then vascular consult to consider need for IVC filter or thrombolysis if massive thrombosis.

• if minor below knee thrombosis and relative C/I to warfarin then:
  • consider aspirin (acetylsalicylic acid) only (1x 300mg tablet per day) with rpt US in 7 days and at 14 days and if becomes above knee then re-consider risk/benefit of warfarin Rx.
• if below knee DVT and no other C/I to outpatient care, then commence anticoagulation either via:
  • hospital in the home:
    • consider admission to short stay observation unit (SSU) if delays in obtaining home nursing Mx.
  • LMO only Rx with warfarin (no longer recommended unless cannot use apixaban):
    • guidelines on starting anticoagulation and warfarin Rx - good to print out for GPs
    • if minor DVT, then consider just a stat dose enoxaparin 1mg/kg s/c and start warfarin
    • if more significant DVT, then consider enoxaparin 1mg/kg bd s/c until INR therapeutic following starting warfarin Rx.
      • enoxaparin 1.5mg/kg once daily sc may be used if not high risk such as iliac vein thrombosis, obese or has cancer.
      • patient may be suitable for self-injecting enoxaparin with education, otherwise via LMO or worse case, return to ED.
    • consider option of 1 week Rx with enoxaparin without warfarin, then rpt USS at 1 week, if no propagation, with-hold warfarin Rx, and repeat USS in another week (ie. day 14), if still no propagation then just Mx with support stockings.
  • outpatient Rx with apixaban:
    • apixaban appears to be safer than rivaroxaban for those with DVT/PE as it appears to halve the risk of major bleeding (3.3% vs 7.1% with rivaroxaban)¹⁾
      • if minor below knee DVT, consider repeat US in 1-2wks and if no propagation, can cease Rx