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Superficial Thrombophlebitis: Treatment & Medication
Updated: Feb 27, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
The treatment of superficial venous thrombosis depends on its etiology, extent, and symptoms. Duplex scanning gives an accurate appraisal of the extent of disease and thus allows determining more rational therapy.
- For the superficial, localized, mildly tender area of thrombophlebitis that occurs in a varicose vein, treatment with mild analgesics, such as aspirin, and the use of some type of elastic support usually are sufficient. Patients are encouraged to continue their usual daily activities. If extensive varicosities are present or if symptoms persist, phlebectomy of the involved segment may be indicated.
- More severe thrombophlebitis, as indicated by the degree of pain and redness and the extent of the abnormality, should be treated by bedrest with elevation of the extremity and the application of massive, hot, wet compresses. The latter measure seems to be more effective when a large, bulky dressing, including a blanket and plastic sheeting followed by hot water bottles, is used, taking care to avoid burning the patient. The immobilization is probably as beneficial as the moist heat. Long-leg heavy-gauge elastic stockings or multiple elastic (Ace) bandages are indicated when the patient becomes ambulatory.
- Patients who present with thrombosis of the long or short saphenous veins should be considered for anticoagulation or ligation of the saphenous vein. A high incidence (6-44%) of concurrence or progression to deep venous thrombosis has been reported. Ascher et al reported that 65.6% of patients who present with long saphenous vein thrombosis were found to have associated deep vein thrombosis.11 Optimal treatment of saphenous thrombosis remains controversial. As noted by Wichers et al in a recent systematic review, a lack of randomized trials prevents evidence-based recommendations in this area.12
- In a small randomized trial of 60 patients with long saphenous thrombosis, Lozano et al compared treatment using low molecular weight heparin (LMWH) with surgical saphenous ligation.13 Patients in the LMWH group experienced no episodes of deep vein thrombosis or pulmonary embolism but had a 10% incidence of recurrent superficial vein thrombosis. Patients treated surgically were found to have 2 pulmonary emboli (6.7%) and 1 episode of recurrent superficial vein thrombosis (3.3%).
- In a larger randomized trial (Stenox study), 436 patients with superficial vein thrombosis were randomized to placebo treatment compared with nonsteroidal anti-inflammatory drugs (NSAIDs) or 2 doses of LMWH. All patients wore compression stockings. No statistical difference in the incidence of deep vein thrombosis or pulmonary embolism between the groups was found. The placebo group had a higher incidence of recurrent superficial vein thrombosis than the other 3 groups. Interestingly, the group treated with NSAIDs was no different than those treated with LMWH.
- Wichers et al conclude, after systematic review of the literature, that LMWH or NSAID therapy appears to reduce the incidence of superficial vein thrombosis extension or recurrence.12 Larger trials are likely required to demonstrate differences in the incidence of deep vein thrombosis. Treating patients with some form of low- or intermediate-dose anticoagulation appears reasonable at this time, followed by repeat duplex ultrasound to look for progression at intervals for a few weeks to a month. In patients with stable nonprogressing thrombus, anticoagulation therapy can probably be discontinued in the absence of other risk factors.
- Patients with contraindications to anticoagulation or those receiving adequate anticoagulation treatment who have progression of thrombosis should be considered for saphenous ligation at the junction with the deep venous system.
- If the thrombophlebitis is associated with a cannula or a catheter, the device should be immediately removed and cultured. If the patient is septic, appropriate antibiotics should be given. If suppurative thrombophlebitis is suspected, immediate and complete excision of all of the involved veins is indicated. The wound may be left packed open for secondary closure or skin grafting at a later date. The use of appropriate systemic antibiotics is always indicated.
- If the suppurative process involves one of the deep veins, aggressive antimicrobial and anticoagulant therapy are necessary.
Activity
In the early phases of superficial thrombophlebitis in the leg, dangling the extremity without external support from stockings or elastic bandages leads to leg swelling and increased pain.
Medication
Some anti-inflammatory drugs may be of benefit. Salicylates, indomethacin, and ibuprofen have been reported to be effective. Salicylates, ibuprofen, and dipyridamole have been used as antithrombotic agents, but their effectiveness has not been documented in this setting. Because thrombophlebitis is primarily due to inflammation and fibrin clot, antithrombotic or antiplatelet-aggregating agents would seem to have little value. Anticoagulants are usually not indicated unless the process extends into the deep venous system. In rare cases when persistent inflammation is present in an area of superficial thrombophlebitis, a brief course of LMWH can be used as an alternative to excision of the vein in order to bring the inflammation under control. This treatment alternative may be necessary for management of superficial thrombophlebitis associated with pregnancy.
Antibiotics are usually not necessary unless the process is suppurative. In persistent cases or even as early definitive therapy, excision of the inflammatory process is effective. The wounds usually heal well with primary closure; the inflammatory process, except in suppurative phlebitis, is usually nonbacterial and localized and is removed completely.
Nonsteroidal anti-inflammatory drugs
These agents decrease inflammatory responses and systemically interfere with events leading to inflammation.
Ibuprofen (Ibuprin, Advil, Motrin)
DOC for patients with mild-to-moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Indomethacin (Indochron E-R, Indocin)
Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation; inhibits prostaglandin synthesis.
Adult
25-50 mg PO bid/tid
75 mg SR PO bid; not to exceed 200 mg/d
Pediatric
1-2 mg/kg/d divided PO bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; GI bleeding or renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia occur)
More on Superficial Thrombophlebitis |
| Overview: Superficial Thrombophlebitis |
| Differential Diagnoses & Workup: Superficial Thrombophlebitis |
 Treatment & Medication: Superficial Thrombophlebitis |
| Follow-up: Superficial Thrombophlebitis |
| References |
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References
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Further Reading
Keywords
superficial thrombophlebitis, venous clot, venous swelling, vein clot, vein swelling, thrombophlebitis, thrombosis, venous thrombosis, vein thrombosis, vein thrombus, deep vein thrombosis, deep venous thrombosis, pulmonary embolism, superficial venous thrombosis, traumatic thrombophlebitis, Mondor disease
