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How to Treat Venous Thromboembolism?

Things to note:
Acute management
  • In pulmonary embolism, cardiovascular resuscitation may be necessary and surgery may be undertaken for intractable disease.
  • Superficial thrombosis does not require anticoagulation.
  • Distal venous thrombosis in the lower limbs, i.e. involving tibial veins only, need not be treated with anticoagulants. Monitor patients with repeat ultrasound if anticoagulants are not used. Ultrasonography should be repeated after a week but may be omitted if D-dimer is negative.
  • Advice on prophylaxis should be emphasised.
  • Eliminate all predisposing factors.
  • Prevent deep vein thrombosis

Medical Treatment::
Acute treatment
  • Unfractionated heparin initially, plus simultaneous warfarin.
  • After 4-6 days, heparin is usually stopped and oral warfarin continued when a therapeutic INR level is reached.
  • Heparin and warfarin therapy should overlap for at least 5 days.
For proximal venous thrombosis and/or pulmonary embolism:
  • Unfractionated heparin, SC, 333 units/kg as an initial dose.
    • Follow 12 hours later by 250 units/kg/dose 12 hourly.
  • Evidence indicates that PTT monitoring is not necessary with weight based dosing. However in morbid obesity and renal failure (eGFR < 30 mL/minute) unfractionated heparin should be used with PTT monitoring to maintain the PTT at 1.5 to 2.5 times the control. PTT should be taken 4 hours after SC dose.
  • Low molecular weight heparin, e.g. enoxaparin, SC, 1 mg/kg 12 hourly.
Do not use LMWH in morbid obesity and renal failure (eGFR <30 mL/minute).
Follow with:
Warfarin, oral, 5 mg daily.
  • Adjust dose to keep INR within therapeutic range.
  • Continue warfarin for 3 months if there was a transient precipitating cause.
  • Continue life-long if there is a non-transient precipitating cause or if repeated episodes.
  • Contraindications for warfarin: first trimester and the last month of pregnancy. In these instances, replace with heparin.
  • Most patients can be managed successfully with therapeutic anticoagulation.
  • Thrombolytic therapy is indicated only in patients with angiographically confirmed early pulmonary embolism where haemodynamic stability cannot be achieved. Discuss with a specialist.
Prophylaxis is indicated for most medical and surgical patients.
  • Low molecular weight heparin, e.g:
    • Dalteparin, SC, 5 000 units daily.
  • Unfractionated heparin, SC, 5 000 units 12 hourly.
Although the risk of bleeding is small, in the following patients prophylaxis should only be used under exceptional circumstances:
  • Active bleeding,
  • Intraocular, intracranial or spinal surgery,
  • Lumbar puncture or epidural anaesthesia within 12 hours,
  • Renal insufficiency,
  • Coagulopathy, or
  • Uncontrolled hypertension.
Heparin induced thrombocytopenia
  • A severe immune-mediated drug reaction occurring in 1-5% of patients receiving heparin (unfractionated or low molecular weight heparin) therapy. It presents with thrombocytopenia and thrombosis. Diagnosis needs a high index of suspicion and should be considered if a patient has a 50% drop in platelet count within 5-10 days after initiating heparin therapy. Confirmation is done by positive antibody testing.
  • Stop heparin and refer all patients.

When to refer:
  • Heparin-induced thrombocytopenia.