Superficial Thrombophlebitis in Emergency Medicine Medication

The goals of therapy for superficial phlebitis are to prevent progression into the deep venous system and to hasten the resolution of the inflammatory and thrombotic processes in areas already involved.

Class Summary

Along with LMWHs, NSAIDS are considered first options to resolve symptoms and prevent extension of thromboembolism.

Ibuprofen (Motrin, Ibuprin)

Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Indomethacin (Indocin)

Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation; inhibits prostaglandin synthesis. Available as immediate-release preparation, sustained-release preparation, suppository, and oral suspension.

Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)

Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in decrease of prostaglandin synthesis.

Class Summary

Heparin is essential for patients with superficial thrombophlebitis that is progressive and for those with particular risk factors for progression or recurrence. Heparin should always be used when thrombophlebitis involves the greater saphenous vein. Heparin is the mainstay of treatment when deep system involvement is suggested, but anticoagulation alone does not guarantee a successful outcome. The disease may progress despite full and effective heparin anticoagulation.

Heparin works by activating antithrombin III to slow or prevent the progression of venous thrombosis. Heparin does not dissolve existing clot.

Fractionated LMWHs have largely replaced unfractionated heparin in the treatment of superficial phlebitis. LMWHs offer several distinct advantages over unfractionated heparin: they may be used in the outpatient setting, they do not require measurement of the aPTT, they produce more reliable anticoagulation, and they are associated with a lower risk of bleeding.

When unfractionated heparin is used, an aPTT of at least 1.5 times the control value is necessary for a therapeutic effect. To achieve this, unfractionated heparin must be given intravenously in adequate doses. Low-dose subcutaneous unfractionated heparin should not be used, as it is not an effective therapy for thrombophlebitis and it is not an effective prophylaxis against progression of the disease.

Warfarin should not be used in the acute treatment of superficial phlebitis, because the early risk of increased thrombogenesis outweighs any convenience of oral therapy.

Enoxaparin (Lovenox)

First LMWH released in US. Only LMWH now approved by FDA for both treatment and prophylaxis of DVT.

Widely used in pregnancy, although clinical trials not yet available to demonstrate that it is as safe as unfractionated heparin.

No utility in checking aPTT (drug has wide therapeutic window and aPTT does not correlate with anticoagulant effect).

Heparin

Initial bolus used for patients with inflammatory or septic thrombosis lower than that needed for spontaneous deep vein thrombosis and pulmonary embolism, because most patients with inflammatory or septic thrombophlebitis do not have underlying hypercoagulability. Patients with DVT and PE require more aggressive therapy because DVT is manifestation of active hypercoagulable state.

Do not check aPTT until 6 h after initial bolus, as extremely high or low value during this time should not provoke any action.

Class Summary

These agents are not routinely useful in nonseptic superficial phlebitis. Antibiotics are indicated whenever infection is suspected to play a role and whenever phlebitis of the greater saphenous vein above the knee threatens to approach the saphenofemoral junction. The choice of antibiotics should be guided by blood culture results whenever possible, but empiric therapy should at a minimum provide coverage for group A streptococci and for Staphylococcus aureus.

Superficial phlebitis must not be confused with septic phlebitis, which can be life threatening. If septic phlebitis is suspected, the selection of antibiotics is critically important and depends upon the clinical setting. Antibiotics for septic phlebitis are discussed in the article Thrombophlebitis, Septic.

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins. When used for treatment of phlebitis, should be administered IV rather than IM.

Effective in superficial phlebitis and bacterial septicemia caused by S aureus, Staphylococcus epidermidis, Streptococcus pyogenes, Viridans group streptococci, E coli, Enterobacter cloacae, Streptococcus pneumoniae, Haemophilus influenzae, Klebsiella oxytoca, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Morganella morganii, Serratia marcescens, Acinetobacter calcoaceticus, Bacteroides fragilis, and various Peptostreptococcus species.

Cephalexin (Keflex, Biocef, Keftab)

First-generation cephalosporin that may be used as adjunctive therapy in superficial phlebitis where infection is possible but unlikely, and where only likely organisms would be skin flora, including staphylococci and streptococci.