Anticoagulation for VTE is divided into phases: initial phase (first week after diagnosis), long-term phase (second week to three months), and extended phase (beyond three months)
Current guidelines recommend anticoagulation for a minimum of 3 months if there are no contraindications. Anticoagulation beyond 3 months should be individualized based on a risk/benefit analysis
| Phase 1 (1st Week After Diagnosis) | Phase 2 (2nd Week to 3 months) | Extended Phase (Beyond 3 months) |
| 1.Parenteral anticoagulation with LMWH (preferred) or Heparin*
2.Decide on the oral anticoagulant for phase 2. 3.If you choose warfarin, dabigatran, or edoxaban for phase 2, LMWH or unfractionated heparin must be given concomitantly for at least 5 days and, in the case of warfarin, until the INR becomes therapeutic (2-3) for 24 hours. 4.Rivaroxaban (Xarelto) and Apixaban (Eliquis) and do not require concomitant use of LMWH or heparin at initiation. I prefer these two. Discharge planning and Followup. |
During phase two, evaluate the patient periodically for adherence and complications of treatment, especially bleeding. How often? The frequency of physician visits should be individualized based on patient knowledge and adherence, and on which therapy is selected.
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Anticoagulation beyond 3 months should be individualized based on a risk/benefit analysis. |
*Inpatient treatment of VTE begins with parenteral agents, preferably LMWH. Unfractionated heparin is preferred over LMWH if a patient is hemodynamically unstable, has severe renal insufficiency, high bleeding risk, or morbid obesity. “
Outpatient tx is with LMWH for phase 1 and then DOAC or Warfarin for phase 2 and extended phase.