Deep Venous Thrombosis (DVT) Medication

Updated: Jul 06, 2017
  • Author: Kaushal (Kevin) Patel, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Medication

Medication Summary

The goals of pharmacotherapy for deep venous thrombosis (DVT) are to reduce morbidity, to prevent the postthrombotic syndrome (PTS), and to prevent pulmonary embolism (PE), all with minimal adverse effects and cost. The main agent classes include anticoagulants and thrombolytics.

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Anticoagulants

Class Summary

These agents prevent recurrent or ongoing thrombolytic occlusion of the vertebrobasilar circulation.

Rivaroxaban (Xarelto)

Rivaroxaban is an oral factor Xa inhibitor that inhibits platelet activation by selectively blocking the active site of factor Xa without requiring a cofactor (eg, antithrombin III) for activity. It is indicated for treatment of deep venous thrombosis (DVT) or pulmonary embolism (PE), and to reduce risk of recurrent DVT and PE following initial treatment. It is also indicated for prophylaxis of DVT in patients undergoing knee or hip replacement surgery.

Apixaban (Eliquis)

Apixaban is an oral factor Xa inhibitor that inhibits platelet activation by selectively and reversibly blocking the active site of factor Xa without requiring a cofactor (eg, antithrombin III) for activity. It inhibits free and clot-bound factor Xa, and prothrombinase activity; no direct effect on platelet aggregation, but indirectly inhibits platelet aggregation induced by thrombin. It is indicated for prophylaxis of deep venous thrombosis (DVT) or pulmonary embolism (PE) in adults undergoing knee or hip replacement surgery. It is also indicated for treatment of DVT and PE and for prevention of recurrence (following the initial 6 months of the initial treatment).

Dabigatran (Pradaxa)

Dabigatran inhibits free and clot-bound thrombin and thrombin-induced platelet aggregation. It is indicated for the prevention of stroke and systemic embolism associated with nonvalvular atrial fibrillation (NVAF). This agent is also indicated for the prevention and treatment of deep venous thrombosis (DVT) or pulmonary embolism (PE).

Edoxaban (Savaysa)

Edoxaban is indicated to reduce the risk of stroke and systemic embolism associated with nonvalvular atrial fibrillation (NVAF). 

Betrixaban (Bevyxxa)

Betrixaban is indicated for the prophylaxis of venous thromboembolism (VTE) in adults hospitalized for acute medical illness who are at risk for thromboembolic complications owing to moderate or severe restricted mobility and other risk factors that may cause VTE.

Fondaparinux sodium (Arixtra)

Fondaparinux sodium is a synthetic anticoagulant that works by inhibiting factor Xa, a key component involved in blood clotting. It provides a highly predictable response and has a bioavailability of 100%. The drug has a rapid onset of action and a half-life of 14-16 hours, allowing for sustained antithrombotic activity over 24-hour period. Fondaparinux sodium does not affect prothrombin time or activated partial thromboplastin time, nor does it affect platelet function or aggregation.

Heparin

Heparin augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin. It does not actively lyse but is able to inhibit further thrombogenesis. Heparin prevents reaccumulation of a clot after a spontaneous fibrinolysis.

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Low Molecular Weight Heparins

Class Summary

Low-molecular-weight-heparin (LMWH) is prepared by selectively treating unfractionated heparin (UFH) to isolate the low molecular weight (<9000 Da) fragments. Its activity is measured in units of factor X inactivation, and monitoring of the activated partial thromboplastin time (aPTT) is not required. The dose is weight adjusted. Enoxaparin (Fragmin), dalteparin (Lovenox), and tinzaparin (Innohep) have received US Food and Drug Administration (FDA) approval for the treatment of deep venous thrombosis (DVT) in the United States. Enoxaparin is approved for inpatient and outpatient treatment of DVT.

Dalteparin (Fragmin)

Dalteparin enhances inhibition of factor Xa and thrombin by increasing antithrombin III activity. In addition, it preferentially increases inhibition of factor Xa. Except in overdoses, no utility exists in checking prothrombin time (PT) or activated partial thromboplastin time (aPTT) because aPTT does not correlate with anticoagulant effect of fractionated low-molecular-weight heparin (LMWH). The average duration of treatment is 7-14 days.

Enoxaparin (Lovenox)

Enoxaparin is a low-molecular-weight (LMWH) used in treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE) as well as DVT prophylaxis. It enhances inhibition of factor Xa and thrombin by increasing antithrombin III activity, it slightly affects thrombin and clotting time, and it preferentially increases inhibition of factor Xa. The average duration of treatment is 7-14 days.

Tinzaparin (Innohep)

Tinzaparin enhances inhibition of factor Xa and thrombin by increasing antithrombin III activity. In addition, it preferentially increases inhibition of factor Xa. The average duration of treatment is 7-14 days.

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Vitamin K Antagonists

Class Summary

Coumarins are a class of oral anticoagulant drugs that act as antagonists to vitamin K. The mechanism of action is to interfere with the interaction between vitamin K and coagulation factors II, VII, IX, and X. Vitamin K acts as a cofactor at these levels. Coumarins produce their anticoagulant effect by inhibiting the carboxylation necessary for biologic activity.

Warfarin (Coumadin)

Warfarin interferes with hepatic synthesis of vitamin K–dependent coagulation factors. It is used for prophylaxis and treatment of venous thrombosis, pulmonary embolism (PE), and thromboembolic disorders. The dose must be individualized and adjusted to maintain an international normalized ratio (INR) of 2-3.

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Thrombolytics

Class Summary

These agents are used to dissolve a pathologic intraluminal thrombus or embolus that has not been dissolved by the endogenous fibrinolytic system. Also used for the prevention of recurrent thrombus formation and rapid restoration of hemodynamic disturbances.

Tenecteplase (TNKase)

Tenecteplase is a modified version of alteplase (tPA) made by substituting 3 amino acids of alteplase. It has a longer half-life and, thus, can be given as a single bolus over 5 seconds infusion instead of 90 minutes with alteplase. It appears to cause less non-intracranial bleeding but has similar risk of intracranial bleeding and stroke as alteplase. The dose should be determined on the basis of patient weight. Treatment should be initiated as soon as possible after onset of acute myocardial infarction symptoms. Because tenecteplase contains no antibacterial preservatives, it must be reconstituted immediately before use.

Alteplase, tPA (Activase)

Alteplase is a thrombolytic agent for deep venous thrombosis (DVT) or pulmonary embolism (PE). It is a tissue plasminogen activator (tPA) produced by recombinant DNA and used in the management of acute myocardial infarction, acute ischemic stroke, and PE. The safety and efficacy of this regimen with coadministration of heparin and aspirin during the first 24 hours after symptom onset have not been investigated.

Reteplase (Retavase)

Reteplase is a tissue plasminogen activator (tPA) produced by recombinant DNA and used in the management of acute myocardial infarction, acute ischemic stroke, and pulmonary embolism (PE). Heparin and aspirin are usually given concomitantly and after reteplase.

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