Venous Thromboembolism (VTE) Guidelines

Updated: Nov 05, 2020
  • Author: Vera A De Palo, MD, MBA, FCCP; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
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Guidelines

ASH Updated Recommendations for Management of VTE (2020)

The American Society of Hematology (ASH) released their updated recommendations on the management of venous thromboembolism (VTE) (deep vein thrombosis [DVT] and pulmonary embolism [PE]) in October 2020. [89] Select recommendations are outlined below.

Strong Recommendations

For patients with PE and hemodynamic compromise, it is recommended that thrombolytic therapy followed by anticoagulation be used over anticoagulation alone.

For patients with DVT and/or PE who have completed primary treatment and will continue vitamin K antagonist (VKA) therapy as secondary prevention, it is recommended that an international normalized ratio (INR) range of 2.0 to 3.0 be used over a lower INR range (eg, 1.5-1.9).

For patients with a recurrent unprovoked DVT and/or PE, indefinite antithrombotic therapy is recommended over stopping anticoagulation after completion of primary treatment.

Conditional Recommendations

Initial management

For patients with DVT and/or PE, the ASH guideline panel suggests using direct oral anticoagulants (DOACs) over VKAs. No single DOAC is suggested over another.

In most patients with proximal DVT, anticoagulation therapy alone is suggested over thrombolytic therapy in addition to anticoagulation.

For patients with PE with echocardiography and/or biomarkers that are compatible with right ventricular dysfunction but without hemodynamic compromise (submassive PE), anticoagulation alone is suggested over the routine use of thrombolysis in addition to anticoagulation.

For patients with extensive DVT in whom thrombolysis is considered appropriate, the ASH guideline panel suggests using catheter-directed thrombolysis over systemic thrombolysis.

For patients with PE in whom thrombolysis is considered appropriate, systemic thrombolysis is suggested over catheter-directed thrombolysis.

For patients with proximal DVT and significant preexisting cardiopulmonary disease, as well as for patients with PE and hemodynamic compromise, use of anticoagulation alone is suggested rather than anticoagulation plus insertion of an inferior vena cava (IVC) filter.

Primary treatment

For primary treatment of patients with DVT and/or PE, whether provoked by a transient risk factor or by a chronic risk factor or unprovoked, using a shorter course of anticoagulation for primary treatment (3-6 months) is suggested over a longer course of anticoagulation for primary treatment (6-12 months).

Secondary prevention

To guide the duration of anticoagulation for patients with unprovoked DVT and/or PE, the ASH guideline panel suggests against routine use of prognostic scores, D-dimer testing, or ultrasonography to detect residual vein thrombosis.

Indefinite antithrombotic therapy is suggested over anticoagulation cessation after completion of primary treatment for the following:

  • Patients with DVT and/or PE provoked by a chronic risk factor
  • Patients with unprovoked DVT and/or PE

For patients with DVT and/or PE who have completed primary treatment and will continue to receive secondary prevention, use of anticoagulation is suggested over aspirin.

For patients with DVT and/or PE who have completed primary treatment and will continue with a DOAC for secondary prevention, the ASH guideline panel suggests using a standard-dose DOAC or a lower-dose DOAC.

Recurrent events

For patients with breakthrough DVT and/or PE during therapeutic VKA treatment, the ASH guideline panel suggests using low-molecular-weight heparin (LMWH) over DOAC therapy.

For patients who develop DVT and/or PE provoked by a transient risk factor and have a history of previous unprovoked VTE or VTE provoked by a chronic risk factor, indefinite antithrombotic therapy is suggested over stopping anticoagulation after completing primary treatment.

For patients who develop DVT and/or PE provoked by a transient risk factor and have a history of a previous VTE also provoked by a transient risk factor, anticoagulation cessation after completion of primary treatment is suggested over indefinite antithrombotic therapy.

Other

For patients with DVT and/or PE with stable cardiovascular disease (CVD) who initiate anticoagulation and were previously taking aspirin for cardiovascular risk modification, it is suggested that aspirin be suspended over continuing it for the duration of anticoagulation therapy.

For patients with DVT, with or without an increased risk for postthrombotic syndrome (PTS), the ASH guideline panel suggests against the routine use of compression stockings.

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ASCO Guidelines for Prevention and Treatment of VTE in Cancer Patients (2019)

In August 2019, the American Society of Clinical Oncology (ASCO) released revised clinical practice guidelines on venous thromboembolism (VTE) prophylaxis and treatment in patients with cancer. [30] Recommendations included the following:

Recommendations regarding anticoagulation for VTE prophylaxis in hospitalized patients with cancer included the following:

  • Hospitalized patients who have active malignancy and acute medical illness or reduced mobility should be offered pharmacologic thromboprophylaxis in the absence of bleeding or other contraindications.
  • Hospitalized patients who have active malignancy without additional risk factors may be offered pharmacologic thromboprophylaxis in the absence of bleeding or other contraindications.
  • Routine pharmacologic thromboprophylaxis should not be offered to patients admitted for the sole purpose of minor procedures or chemotherapy infusion, nor to patients undergoing stem-cell/bone marrow transplantation.

Recommendations regarding anticoagulation for VTE prophylaxis during systemic chemotherapy in ambulatory patients with cancer included the following:

  • Routine pharmacologic thromboprophylaxis should not be offered to all outpatients with cancer.
  • High-risk outpatients with cancer (Khorana score of 2 or higher prior to starting a new systemic chemotherapy regimen) may be offered thromboprophylaxis with apixaban, rivaroxaban, or low-molecular-weight heparin (LMWH), provided that there are no significant risk factors for bleeding and no drug interactions. Consideration of such therapy should be accompanied by a discussion with the patient about the relative benefits and harms, drug cost, and duration of prophylaxis in this setting.
  • Patients with multiple myeloma receiving thalidomide- or lenalidomide-based regimens with chemotherapy and/or dexamethasone should be offered pharmacologic thromboprophylaxis with either aspirin or LMWH for lower-risk patients and LMWH for higher-risk patients.

Recommendations regarding perioperative VTE prophylaxis in patients with cancer undergoing surgery included the following:

  • All patients with malignant disease undergoing major surgical intervention should be offered pharmacologic thromboprophylaxis with either unfractionated heparin (UFH) or LMWH unless contraindicated because of active bleeding, or high bleeding risk, or other contraindications.
  • Prophylaxis should be commenced preoperatively.
  • Mechanical methods may be added to pharmacologic thromboprophylaxis but should not be used as monotherapy for VTE prevention unless pharmacologic methods are contraindicated because of active bleeding or high bleeding risk.
  • A combined regimen of pharmacologic and mechanical prophylaxis may improve efficacy, especially in the highest-risk patients.
  • Pharmacologic thromboprophylaxis for patients undergoing major surgery for cancer should be continued for at least 7-10 days. Extended prophylaxis with LMWH for up to 4 weeks postoperatively is recommended for patients undergoing major open or laparoscopic abdominal or pelvic surgery for cancer who have high-risk features, such as restricted mobility, obesity, history of VTE, or additional risk factors. In lower-risk surgical settings, the decision on appropriate duration of thromboprophylaxis should be made on a case-by-case basis.

Recommendations regarding the best method for treating cancer patients with established VTE to prevent recurrence included the following:

  • Initial anticoagulation may involve LMWH, UFH, fondaparinux, or rivaroxaban. For patients initiating treatment with parenteral anticoagulation, LMWH is preferred over UFH for the initial 5 to 10 days of anticoagulation for the patient with cancer with newly diagnosed VTE who does not have severe renal impairment (defined as creatinine clearance less than 30 mL/min).
  • For long-term anticoagulation, LMWH, edoxaban, or rivaroxaban for at least 6 months are preferred because of improved efficacy over vitamin K antagonists (VKAs). VKAs are inferior but may be used if LMWH or direct oral anticoagulants (DOACs) are not accessible. There is an increase in major bleeding risk with DOACs, particularly observed in GI and potentially genitourinary malignancies. Caution with DOACs is also warranted in other settings with high risk for mucosal bleeding. Drug-drug interaction should be checked prior to using a DOAC.
  • Anticoagulation with LMWH, DOACs, or VKAs beyond the initial 6 months should be offered to select patients with active cancer, such as those with metastatic disease or those receiving chemotherapy. Anticoagulation beyond 6 months needs to be assessed on an intermittent basis to ensure a continued favorable risk-benefit profile.
  • Based on expert opinion in the absence of randomized trial data, uncertain short-term benefit, and mounting evidence of long-term harm from filters, the insertion of a vena cava filter should not be offered to patients with established or chronic thrombosis (VTE diagnosis more than 4 weeks ago), nor to patients with temporary contraindications to anticoagulant therapy (eg, surgery). There also is no role for filter insertion for primary prevention or prophylaxis of pulmonary embolism (PE) or deep vein thrombosis due to its long-term harm concerns. It may be offered to patients with absolute contraindications to anticoagulant therapy in the acute treatment setting (VTE diagnosis within the past 4 weeks) if the thrombus burden was considered life-threatening. Further research is needed.
  • The insertion of a vena cava filter may be offered as an adjunct to anticoagulation in patients with progression of thrombosis (recurrent VTE or extension of existing thrombus) despite optimal anticoagulant therapy. This is based on the panel’s expert opinion given the absence of a survival improvement, a limited short-term benefit, but mounting evidence of the long-term increased risk for VTE.
  • For patients with primary or metastatic CNS malignancies and established VTE, anticoagulation as described for other patients with cancer should be offered, although uncertainties remain about choice of agents and selection of patients most likely to benefit.
  • Incidental PE and deep vein thrombosis should be treated in the same manner as symptomatic VTE, given their similar clinical outcomes compared with patients with cancer with symptomatic events.
  • Treatment of isolated subsegmental PE or splanchnic or visceral vein thrombi diagnosed incidentally should be offered on a case-by-case basis, considering potential benefits and risks of anticoagulation.

Recommendations regarding the use of anticoagulants to improve survival in patients with cancer in the absence of established VTE included the following:

  • Anticoagulant use is not recommended to improve survival in patients with cancer without VTE.

Recommendations regarding risk prediction and awareness of VTE among patients with cancer included the following:

  • There is substantial variation in VTE risk between individual patients with cancer and cancer settings. Patients with cancer should be assessed for VTE risk initially and periodically thereafter, particularly at the start of systemic antineoplastic therapy or at the time of hospitalization. Individual risk factors, including biomarkers or cancer site, do not reliably identify patients with cancer at high risk for VTE. In the ambulatory setting among patients with solid tumors treated with systemic therapy, risk assessment can be conducted with a validated risk assessment tool (eg, Khorana score).
  • Oncologists and members of the oncology team should educate patients regarding VTE, particularly in settings that increase risk, such as major surgery, hospitalization, and ongoing systemic antineoplastic therapy.

With regard to off-label use in guideline recommendations, apixaban, rivaroxaban, and LMWH have not been approved by the US Food and Drug Administration (FDA) for thromboprophylaxis in outpatients with cancer. Dalteparin is the only LMWH approved by the FDA for extended therapy to prevent recurrent thrombosis in patients with cancer.

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ASH Guidelines for Diagnosis of VTE (2018)

In November 2018, the American Society of Hematology (ASH) released guidelines for the diagnosis of venous thromboembolism (VTE). [20] The American Academy of Family Physicians (AAFP) endorsed these guidelines in March 2019 and provided the following key recommendations from the guidelines. [90]

D-dimer testing alone should not be used to rule in or diagnose pulmonary embolism (PE), and a positive D-dimer alone should not be used to diagnose deep vein thrombosis (DVT).

Pulmonary embolism

In individuals with a low or intermediate pretest probability or prevalence, clinicians should use a D-dimer strategy to rule out PE, followed by a ventilation-perfusion (VQ) scan or computed tomography pulmonary angiography (CTPA) in patients requiring additional testing. D-dimer testing alone should not be used to rule in a PE.

In individuals with a high pretest probability or prevalence (≥50%), clinicians should start with CTPA to diagnose PE. If CTPA is not available, a VQ scan should be used with appropriate follow-up testing.

In individuals with a high pretest probability or prevalence, D-dimer testing alone should not be used to diagnose PE and should not be used as a subsequent test after CT.

In individuals with a positive D-dimer or likely pretest probability, CTPA should be performed. D-dimer testing can be used to exclude recurrent PE in individuals with an unlikely pretest probability.

In outpatients older than 50 years, use of an age-adjusted D-dimer cutoff is safe and improves the diagnostic yield. Age-adjusted cutoff = Age (years) × 10 µg/L (using D-dimer assays with a cutoff of 500 µg/L).

Lower-extremity deep vein thrombosis

In individuals with a low pretest probability or prevalence of lower-extremity (LE) DVT, clinicians should use a D-dimer strategy to rule out DVT, followed by proximal LE or whole-leg ultrasonography (US) in patients requiring additional testing.

In individuals with a low pretest probability or prevalence (≤ 10%), a positive D-dimer alone should not be used to diagnose DVT, and additional testing following negative proximal or whole-leg US should not be conducted.

In individuals with an intermediate pretest probability or prevalence (~25%), whole-leg or proximal LE US should be used. Serial proximal US testing is needed after a negative proximal ultrasonogram. No serial testing is needed after a negative whole-leg ultrasonogram.

In individuals with suspected DVT and a high pretest probability or prevalence (≥50%), whole-leg or proximal LE US should be used. Serial US should be used if the initial ultrasonogram is negative and no alternative diagnosis is identified.

Upper-extremity deep vein thrombosis

In individuals with a low prevalence/unlikely pretest probability of upper-extremity (UE) DVT, D-dimer testing should be used to exclude UE DVT, followed by duplex US if findings are positive.

In individuals with a high prevalence/likely pretest probability, either (a) D-dimer testing followed by duplex US/serial duplex US or (b) duplex US/serial duplex US alone can be used for assessing patients suspected of having a UE DVT.

A positive D-dimer alone should not be used to diagnose UE DVT.

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ASH Guidelines for Optimal Management of Anticoagulation Therapy for VTE (2018)

In November 2018, the American Society of Hematology (ASH) released the following guidelines on optimal management of anticoagulation therapy for venous thromboembolism (VTE). [28]

Initial anticoagulant dose selection

In obese patients receiving low-molecular-weight heparin (LMWH) for treatment of acute VTE, it is suggested that initial LMWH dose selection be based on actual body weight rather than on a fixed maximum daily dose (ie, capped dose).

Drug-interaction management

For patients requiring administration of inhibitors or inducers of P-glycoprotein (P-gp) or strong inhibitors or inducers of cytochrome P450 (CYP) enzymes, it is suggested to use an alternative anticoagulant (eg, a vitamin K antagonist [VKA] or LMWH) rather than a direct oral anticoagulant (DOAC) to treat VTE.

Point-of-care INR testing

For patients receiving maintenance VKA therapy for VTE, home point-of-care international normalized ratio (INR) testing (patient self-testing [PST]) is suggested in preference to any other INR testing approach except patient self-management (PSM) in suitable patients (those who have demonstrated competency to perform PST and who can afford this option).

For patients receiving maintenance VKA therapy for VTE, point-of-care INR testing by the patient at home with self-adjustment of VKA dose (PSM) is suggested in preference to any other management approach, including PST in suitable patients (those who have demonstrated competency to perform PSM and who can afford this option).

Selection of timing between INR measurements (INR recall interval)

For patients receiving VKA therapy for VTE, an INR recall interval of 4 weeks or less is suggested rather than an interval longer than 4 weeks after VKA dose adjustment due to an out-of-target-range INR.

For patients receiving maintenance VKA therapy for VTE, a longer (6-12 weeks) INR recall interval is suggested rather than a shorter (4 weeks) interval during periods of stable INR control.

Laboratory monitoring of anticoagulant response

For patients with renal dysfunction (creatinine clearance, < 30 mL/min) or obesity receiving LMWH therapy for VTE, it is suggested not to use anti–factor Xa concentration monitoring to guide LMWH dose adjustment.

For patients receiving DOAC therapy for VTE, it is suggested not to measure the DOAC anticoagulant effect during management of bleeding.

Transitions between anticoagulants

For patients transitioning from DOAC to VKA, overlapping DOAC and VKA therapy until the INR is within the therapeutic range is suggested in preference to LMWH or UFH “bridging therapy.”

Use of specialized AMS

For patients receiving anticoagulation therapy for VTE, specialized anticoagulation-management service (AMS) care is suggested in preference to care provided by the patient’s usual healthcare provider.

Structured patient education

For patients receiving oral anticoagulation therapy for VTE, supplementary patient education is suggested in addition to basic education.

Efforts to improve adherence to anticoagulant regimen

For patients receiving anticoagulation therapy for VTE, it is suggested not to use a daily lottery, electronic reminders, or a combination of the two to improve medication adherence. It is also suggested not to use visual medication schedules (provided to patients at each visit, along with brief counseling) to improve medication adherence.

Invasive procedure management

For patients at low-to-moderate risk for recurrent VTE who require interruption of VKA therapy for invasive procedures, VKA interruption alone is recommended in preference to periprocedural bridging with LMWH or UHF.

For patients interrupting DOAC therapy for scheduled invasive procedures, it is suggested not to perform laboratory testing for DOAC effect before procedures.

Excessive anticoagulation and bleeding management

For patients receiving VKA therapy for VTE with INR >4.5 but < 10 and without clinically relevant bleeding, temporary cessation of VKA alone is suggested, without the addition of vitamin K.

For patients with life-threatening bleeding during VKA therapy for VTE and an elevated INR, use of four-factor prothrombin complex concentrates (PCCs) is suggested in preference to fresh frozen plasma (FFP) as an addition to cessation of VKA and IV vitamin K.

For patients with life-threatening bleeding during oral direct Xa inhibitor therapy for VTE, it is suggested to use either four-factor PCC administration as an addition to cessation of oral direct Xa inhibitor or cessation of oral direct Xa inhibitor alone.

For patients with life-threatening bleeding during oral direct Xa inhibitor therapy for VTE, it is suggested to use coagulation factor Xa (recombinant), inactivated-zhzo in addition to cessation of oral direct Xa inhibitor rather than no coagulation factor Xa (recombinant), inactivated-zhzo.

For patients with life-threatening bleeding during dabigatran therapy for VTE, it is suggested to use idarucizumab in addition to cessation of dabigatran rather than no idarucizumab.

For patients with life-threatening bleeding during LMWH or unfractionated heparin (UFH) therapy for VTE, it is suggested to use protamine in addition to LMWH/UFH cessation rather than no protamine.

Anticoagulant resumption following bleeding

For patients receiving anticoagulation therapy for VTE who survive an episode of major bleeding, resumption of oral anticoagulation therapy within 90 days is suggested in preference to discontinuance of oral anticoagulation therapy.

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ESA Guidelines for VTE Prophylaxis in Elderly Surgical Patients (2017)

In September 2017, the European Society of Anesthesiology (ESA) issued the following guidelines regarding prophylaxis for VTE in elderly patients undergoing surgery [84] :

  • The risk for postoperative VTE is increased in patients older than 70 years and in elderly patients presenting with comorbidities, such as cardiovascular disorders, malignancy, or renal insufficiency; therefore, risk stratification, correction of modifiable risks, and sustained perioperative thromboprophylaxis are essential in this patient population
  • Timing and dosing of pharmacoprophylaxis may be adopted from the younger population
  • Direct oral anticoagulants are effective and well tolerated in the elderly; statins may not replace pharmacologic thromboprophylaxis
  • Early mobilization and use of nonpharmacologic means of thromboprophylaxis should be exploited
  • In elderly patients, suggest identification of comorbidities increasing the risk for VTE (eg, congestive heart failure, pulmonary circulation disorder, renal failure, lymphoma, metastatic cancer, obesity, arthritis, post-menopausal estrogen therapy) and correction if present (eg, anemia, coagulopathy)
  • Suggest against bilateral knee replacement in elderly and frail patients
  • Suggest timing and dosing of pharmacologic VTE prophylaxis as in the younger population
  • In elderly patients with renal failure, low-dose unfractionated heparin (UFH) may be used or weight-adjusted dosing of low-molecular-weight heparin (LMWH)
  • In the elderly, recommend careful prescription of postoperative VTE prophylaxis and early postoperative mobilization
  • Recommend multifaceted interventions for VTE prophylaxis in elderly and frail patients, including pneumatic compression devices, LMWH, and/or direct oral anticoagulants after knee or hip replacement
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ACCP Guidelines for Prevention and Treatment of Thrombosis (2012)

In 2012, the American College of Chest Physicians (ACCP) published the ninth edition of its guidelines on antithrombotic therapy and prevention of thrombosis (updated from the eighth edition published in 2009). [35] ACCP guidelines providing recommendations for the prevention of VTE in orthopedic surgery patients addressed therapy and prevention. [83] Recommendations included the following:

  • In patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA), use of one of the following is recommended for a minimum of 10-14 days rather than no antithrombotic prophylaxis: LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose UFH (LDUH), adjusted-dose vitamin K antagonist (VKA), aspirin (all grade 1B), or an intermittent pneumatic compression device (IPCD) (grade 1C)
  • In patients undergoing hip fracture surgery (HFS), use of one of the following is recommended rather than no antithrombotic prophylaxis for a minimum of 10 to 14 days: LMWH, fondaparinux, LDUH, adjusted-dose VKA, aspirin (all grade 1B), or an IPCD (grade 1C)
  • For patients undergoing major orthopedic surgery (THA, TKA, HFS) and receiving LMWH as thromboprophylaxis, it is recommended to start either 12 hr or more preoperatively or 12 hr or more postoperatively rather than within 4 hr or less preoperatively or 4 hr or less postoperatively (grade 1B)
  • In patients undergoing THA or TKA, irrespective of the concomitant use of an IPCD or length of treatment, LMWH is suggested in preference to the other agents recommended as alternatives: fondaparinux, apixaban, dabigatran, rivaroxaban, LDUH (all grade 2B), adjusted-dose VKA, or aspirin (all grade 2C)
  • In patients undergoing HFS, irrespective of the concomitant use of an IPCD or length of treatment, LMWH is suggested in preference to the other agents recommended as alternatives: fondaparinux, LDUH (grade 2B), adjusted-dose VKA, or aspirin (all grade 2C)
  • For patients undergoing major orthopedic surgery, it is suggested to extend thromboprophylaxis in the outpatient period for up to 35 days from the day of surgery rather than for only 10-14 days (grade 2B)
  • In patients undergoing major orthopedic surgery, dual prophylaxis with an antithrombotic agent and an IPCD is suggested during the hospital stay (grade 2C)
  • In patients undergoing major orthopedic surgery and increased risk of bleeding, an IPCD or no prophylaxis is suggested rather than pharmacologic treatment (grade 2C)
  • In patients undergoing major orthopedic surgery and who decline or are uncooperative with injections or an IPCD, use of apixaban or dabigatran (alternatively, rivaroxaban or adjusted-dose VKA if apixaban or dabigatran are unavailable) is recommended rather than alternative forms of prophylaxis (all grade 1B)
  • In patients undergoing major orthopedic surgery, it is suggested not to use inferior vena cava (IVC) filter placement for primary prevention over no thromboprophylaxis in patients with an increased bleeding risk or contraindications to both pharmacologic and mechanical thromboprophylaxis (grade 2C)
  • For asymptomatic patients following major orthopedic surgery, it is recommended not to perform Doppler (or duplex) ultrasonography (DUS) screening before hospital discharge (grade 1B)
  • No prophylaxis is suggested rather than pharmacologic thromboprophylaxis in patients with isolated lower-leg injuries requiring leg immobilization (grade 2C)
  • For patients undergoing knee arthroscopy without a history of prior VTE, no thromboprophylaxis is suggested rather than prophylaxis (grade 2B)

An update in 2016 addressed 12 topics from the ninth edition guidelines, as well as three new topics. [91]

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AAOS Guidelines for Prevention of VTE in Hip and Knee Arthroplasty (2011)

Guidelines from the American Academy of Orthopaedic Surgeons (AAOS) on preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty included the following recommendations [7] :

  • Recommend against routine postoperative duplex ultrasonography screening
  • Assess risk of previous VTE
  • Assess risk for bleeding
  • Suggest discontinuance of antiplatelet agents before undergoing elective hip or knee arthroplasty
  • Suggest pharmacologic agents and/or mechanical compressive devices for prevention of VTE in those undergoing elective hip or knee arthroplasty who are not at elevated additional risk for VTE or bleeding
  • Pharmacologic prophylaxis and mechanical compressive devices for those who have had previous VTE and are undergoing elective hip or knee arthroplasty
  • Mechanical compressive devices for those who have had known bleeding disorder and/or active liver disease and are undergoing elective hip or knee arthroplasty
  • Patients should undergo early mobilization following elective hip and knee arthroplasty
  • Use of neuraxial anesthesia for those undergoing elective hip or knee arthroplasty to help limit blood loss
  • Unable to recommend for or against the use of inferior vena cava filters
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ITAC Guidelines for Prevention and Treatment of VTE in Cancer Patients (2013)

International clinical practice guidelines for the treatment and prophylaxis of VTE in patients with cancer were issued in early 2013 by the The International Initiative on Thrombosis and Cancer. [29] Recommendations included the following:

  • For the initial treatment of established VTE, LMWH is recommended, and fondaparinux and UFH can be also used
  • Thrombolysis may only be considered on a case-by-case basis
  • Vena cava filters (VCFs) may be considered if there is a contraindication to anticoagulation or PE recurrence under optimal anticoagulation
  • Periodic reassessments of contraindications to anticoagulation are recommended
  • VCFs are not recommended for primary VTE prophylaxis in cancer patients
  • For the early maintenance and long-term treatment of established VTE, LMWH for a minimum of 3 months is preferred over vitamin K antagonists (VKAs). Idraparinux is not recommended. After 3-6 months, LMWH or VKA continuation should be based on individual evaluation of the benefits and risks, tolerability, patient preference and cancer activity
  • For the treatment of VTE recurrence in cancer patients receiving anticoagulation, there are three options: (i) switch from VKA to LMWH when treated with VKA; (ii) increase LMWH dose when treated with LMWH, and (iii) VCF insertion
  • For the prophylaxis of postoperative VTE in surgical cancer patients, use of LMWH or low-dose UFH is recommended
  • Extended prophylaxis (4 weeks) after major laparotomy may be indicated in patients with a high risk of VTE and low risk of bleeding
  • Use of LMWH for VTE prevention in cancer patients undergoing laparoscopic surgery may be recommended as for laparotomy
  • Mechanical methods are not recommended as monotherapy except when pharmacologic methods are contraindicated
  • In hospitalized patients with cancer and reduced mobility, prophylaxis with LMWH, UFH, or fondaparinux is recommended
  • Prophylaxis may be considered in some children and adults with acute lymphocytic leukemia treated with L-asparaginase, depending on local policy and patient characteristics
  • Routine prophylaxis is not recommended in patients receiving chemotherapy
  • Primary pharmacologic prophylaxis of VTE may be indicated in patients with locally advanced or metastatic pancreatic or lung cancer treated with chemotherapy and having a low risk of bleeding
  • In patients treated with thalidomide or lenalidomide combined with steroids and/or chemotherapy, VTE prophylaxis is recommended
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Additional Resources

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