Clotmaster Consensus 2015: Duration of Therapy for Venous Thromboembolic Disease

Superficial Venous Thrombosis: most respond to NSAID/heat but data show that at least a 10-12 day course (up to 42 days) of prophylactic LMWH or fondaparinux is more effective that NSAIDs and should be considered in patients with extensive (> 5cm), greater saphenous, or painful SVT.

Upper Extremity DVT:

Catheter related: In PICC deep venous thrombosis hold anticoagulation unless very symptomatic (pain limited use of arm, thrombus extension into SVC) and then just for 4-6 weeks. Removal of PICC is only treatment associated with resolution of thrombosis. Remember the basilic and cephalic are superficial veins. For tunneled catheters consider removal and 1-3 months therapy depending on bleeding risk and extent of thrombosis. If catheter is not removed then need 3 months of therapy.

Spontaneous: 3 month of therapy. Consider catheter directed thrombolytic therapy for extensive thrombosis especially if in a dominant arm or a young patient - both for symptom relief and to find any anatomical lesions

Muscular Calf Vein (soleus or gastrocnemius) Thrombosis: 10 days of therapeutic LMWH or direct oral anticoagulants.

Calf Vein Thrombosis: 6 weeks of therapy.

Proximal Vein Thrombosis (popliteal vein and above): Duration of therapy influenced by number of thrombosis and presence of provoking factors. Catheter directed therapy is useful for symptomatic common femoral or more proximal thrombosis. Since many of these patients have underlying venous lesions such as May-Thurner syndrome, venoplasty or venous stenting can be done with the lytic therapy.

Provoked first DVT or PE: 3 months.

• Provoking factors: trauma, surgery, bedrest > 72 hours, pregnancy, estrogen, very long (> 10 hours) plane flights.

Idiopathic first DVT or PE: Strongly consider indefinite therapy with warfarin INR 2-3 or direct oral anticoagulants. High risk (10-25%) of recurrence in next 2 years without anticoagulation.

Two or more Lower extremity proximal DVT or PE: Indefinite anticoagulation

.

Pregnancy: LMWH has been established to be both effective and safer in pregnancy than standard heparin. Dose for body weight and check levels after third dose then every month. Can use LMWH or warfarin with breast feeding. Duration – entire course of pregnancy and at least 6 weeks after delivery – total should be at least three months.

Thrombophilia

• Inherited hypercoagulable states – raises risk of first DVT but not a predictor of recurrence. Multiple guidelines recommend not checking in provoked thrombosis

• Severe acquired states – antiphospholipid antibody syndrome, myeloproliferative disease, PNH, cancer – consider long term anticoagulation

Cancer Use of LMWH at least 3-6 month should be considered especially if lung cancer or pancreatic cancer. Long term LMWH is mandatory for warfarin failures. Note that studies have shown that incidentally discovered PE in cancer patients has the same adverse outcome as symptomatic PE and requires aggressive therapy.

Visceral Vein Thrombosis: Portal vein thrombosis - unless discovered incidentally while screening cirrhotics for hepatomas all require anticoagulation. If provoked by surgery or infections 3 months otherwise indefinite. Consider JAK2/PNH screening in idiopathic cases. Budd-Chiari - indefinite anticoagulation and JAK2/PNH screening.

GENERAL REFERENCES

Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines Chest. 2012 Feb;141(2 Suppl):e419S-94S.

Antithrombotic and Thrombolytic Therapy, 8th Ed: ACCP Guidelines

Chest 2008 Jun; 133 (Suppl) : 67S-968S.

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