Medication Summary
Some anti-inflammatory drugs may be of benefit in the treatment of superficial thrombophlebitis. Salicylates, indomethacin, and ibuprofen have been reported to be effective. In addition, salicylates, ibuprofen, and dipyridamole have been used as antithrombotic agents, but their effectiveness has not been documented in this setting. [36]
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. [25]
Additionally, in rare cases in which persistent inflammation is present in an area of superficial thrombophlebitis, a brief course of low-molecular-weight heparin (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 in superficial thrombophlebitis 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
Class Summary
Along with LMWHs, nonsteroidal anti-inflammatory drugs (NSAIDs) are considered first options to resolve symptoms and prevent extension of thromboembolism.
Ibuprofen (Ibu, Advil, Motrin)
Ibuprofen is the drug of choice for patients with mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Indomethacin (Indocin)
Indomethacin, which inhibits prostaglandin synthesis, is rapidly absorbed. Metabolism of the drug occurs in the liver by demethylation, deacetylation, and glucuronide conjugation.
Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
Naproxen inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in decrease of prostaglandin synthesis.
Anticoagulants, Hematologic
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 great 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 clots.
Fractionated LMWHs have largely replaced unfractionated heparin in the treatment of superficial phlebitis. LMWHs offer several distinct advantages over unfractionated heparin, including the following:
- They may be used in the outpatient setting
- They do not require measurement of the activated partial thromboplasting time (aPTT)
- They produce more reliable anticoagulation
- 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 does not provide 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)
Enoxaparin was the first LMWH released in the United States and is the only LMWH now approved by the US Food and Drug Administration (FDA) for both treatment and prophylaxis of deep venous thrombosis (DVT).
It is widely used in pregnancy, although clinical trials are not yet available to demonstrate that it is as safe as unfractionated heparin.
When enoxaparin is used, there is no utility in checking the aPTT (the drug has a wide therapeutic window, and aPTT does not correlate with the anticoagulant effect).
Dalteparin (Fragmin)
Dalteparin is indicated for the prevention of DVT, which may lead to pulmonary embolism (PE). It enhances the inhibition of factor Xa and thrombin by increasing antithrombin III activity. In addition, dalteparin preferentially increases the inhibition of factor Xa. The average duration of treatment is 7-14 days.
Heparin
The initial bolus used for inflammatory or septic thrombosis is lower than that needed for spontaneous DVT and PE, because most patients with inflammatory or septic thrombophlebitis do not have underlying hypercoagulability.
Patients withDVT and PE require more aggressive therapy because DVT is a manifestation of an active hypercoagulable state.
Do not check aPTT until 6 hours after the initial bolus, as an extremely high or low value during this time should not provoke any action.
Antibiotics
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 great 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.
Ceftriaxone (Rocephin)
Ceftriaxone is a third-generation cephalosporin with broad-spectrum, gram-negative activity. It has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. This agent arrests bacterial growth by binding to 1 or more penicillin-binding proteins. When used for the treatment of phlebitis, ceftriaxone should be administered intravenously rather than intramuscularly.
Ceftriaxone is effective in the treatment of superficial phlebitis and bacterial septicemia caused by Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pyogenes, viridans group streptococci, Escherichia 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)
Cephalexin is a first-generation cephalosporin that may be used as adjunctive therapy in superficial phlebitis if infection is possible but unlikely, and if the only likely organisms would be skin flora, including staphylococci and streptococci.
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Deep venous thrombosis.
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Thrombosis of great saphenous vein and tributaries. Note lack of full compressibility of vein secondary to intraluminal thrombus. Courtesy of Wikimedia Commons ©Nevit Dilmen.
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Blood coagulation (thrombin) and protein C pathways. Courtesy of Wikimedia Commons ©John H Griffin, PhD.
