DVT - initial management NSCCG

Transcription

1 Background information Information resources for patients and carers Updates to this care map Synonyms Below knee DVT and bleeding risks Patient with confirmed DVT Scan confirms superficial thrombophlebitis only Mechanical interventions Acute sector treatment started GP sector treatment started Clot extends to within 3cm of saphenofemoral junction Thrombolytic therapy NO YES GP or hospital management Risk factors present No risk factors Pharmacological treatment Other treatments Patient information Stockings Go to Hosiery Rivaroxaban patients LMWH & Warfarin patients Follow up phone call (within 2 days) by GP INR check & daily injections until stable 3 week review and possible re-fit 3 week review for Rivaroxaban patients Once stable or 5 days LMWH discharge back to GP to monitor Go to DVT - on-going management NSCCG Page 1 of 8

2 1 Background information Scope: the diagnosis and management of deep vein thrombosis (DVT) presenting in adults (age 18 years and older) including outpatient management DVT probability assessment model Wells score the different imaging modalities for DVT and the use of D-dimer tests as discriminators anticoagulation therapy Out of scope: patients under age 18 years patients who present with significant and/or disabling co-morbidities Definition: symptomatic DVT is radiologically-confirmed partial or total thrombotic occlusion of the deep venous system of the legs and pelvis sufficient to produce symptoms of pain or swelling proximal DVT affects the veins from the trifurcation of the popliteal vein and above (popliteal, superficial femoral, common femoral, and iliac veins) [17] isolated calf DVT is confined to the deep veins below the trifurcation of the popliteal vein Prevalence and prognosis: DVT has an annual incidence of about 1 in 1000 general population [15] proximal DVT may cause fatal or non-fatal pulmonary embolism (PE); recurrent venous thrombosis; and/or the post-thrombotic syndrome Risk factors include [2]: prior history of DVT cancer and chemotherapy increasing age [17] obesity acquired or familial thrombophilia surgery prolonged travel immobility pregnancy hormone treatment, eg oestrogen-containing contraception or hormone replacement therapy [15] varicose veins with phlebitis [3] References: [2] National Institute for Health and Clinical Excellence (NICE). Venous thromboembolic diseases. Clinical guideline CG144. London: NICE; 2012 [3] National Institute for Health and Clinical Excellence (NICE); Venous thromboembolism: reducing the risk. Clinical guideline CG92. London: NICE; 2010 [15] Clinical Knowledge Summaries (CKS). Deep vein thrombosis. Version 1.2. Newcastle upon Tyne: CKS; [17] Contributors representing Royal College of Physicians; Information resources for patients and carers BNSSG Anticoagulation choices Feb 13 3 Updates to this care map Page 2 of 8

3 DVT - initial management Sign off form 4 Synonyms Deep vein thrombosis DVT Pulmonary embolism PE Venous thromboembolism VTE Superficial venous thrombophlebitis SVT 5 Below knee DVT and bleeding risks If below knee DVT has been detected and patient has any of the following factors: Any recent bleeding episodes Age >65 Thrombocytopenia (platelets <75x10 9 /l) Eye or neurosurgery within last month Multiple comorbidities: e.g. interacting meds/falls risk High alcohol intake (especially binge drinker) Abnormal liver function tests (if known) Concerns over compliance consider not treating with anticoagulation. Rescan in 7 to 10 days In the absence of bleeding risks, below knee DVT should be treated with 6 weeks of standard anticoagulation. 8 Mechanical interventions IVC Filters (Consultant decision only, to be done in an acute setting): Offer temporary Inferior Vena Caval (IVC) filters to patients with proximal DVT in whom anticoagulation is contraindicated and remove if patient becomes eligible for such treatment Ensure a strategy to remove the IVC filter at the earliest opportunity is planned (and documented) when the filter is placed, and that the strategy is reviewed regularly. References: National Institute for Health and Clinical Excellence (NICE). Venous thromboembolic diseases. Clinical guideline CG144. London: NICE; Thrombolytic therapy Consider catheter-directed thrombolytic therapy for patients with symptomatic iliofemoral DVT who have: symptoms of less than 14 days' duration and good functional status and Page 3 of 8

4 a life expectancy of 1 year or more and a low risk of bleeding. NICE guidance 13 NO Treat with NSAIDS If these have ben ineffective, NSAIDS contraindicated (seek advice from Haematologist), >5cm SVT or risk factors present (previous VTE, malignancy, immobility), risk assess for LMWH. Start at prophylactic dose and reassess at 2 weeks. Consider increase to treatment dose if symptoms have progressed 16 Risk factors present If risk factors present (previously VTE, active malignancy, immobility) anticoagulate for 6 weeks. 17 No risk factors No risk factors: prophylactic dose LMWH. Rescan at 1 week and change to therapeutic anticoagulation if no change or progression. 18 Pharmacological treatment Refer to the BNSSG formulary section 2.8 Provoked proximal or transient DVT (inc. IVDU); Offer Rivaroxaban, or Warfarin if rivaroxaban is excluded, for 6-12 weeks. If applicable, review after 6 weeks and continue for 12 weeks if still symptomatic. (Give LMWH tinzaparin or enoxaparin if pregnant - see below) Unprovoked DVT; Offer LMWH and Warfarin for at least 3 months within 24 hours (or 3 months of Rivaroxaban if long term anticoagulation not indicated) Consider thrombophilia testing Consider an extended period of treatment if ongoing symptoms or DVT extensive. Active cancer with proximal DVT; Offer LMWH (tinzaparin or enoxapan) within 24 hours for 6 months, or until cancer is not active. Consider an extended period of treatment Pregnant patients with DVT; Continue anticoagulation throughout pregnancy and 6 8 weeks post-partum Recurrent VTE Lifelong anticoagulation is required Patients with renal impairment; (Creatinine clearance <20ml/min) Offer Unfractionated Heparin (UFH) Patients initiated on Warfarin; Start the LMWH/UFH as soon as possible and continue for 5 days, or until the INR is >2 for at least 24 hours, whichever is the longest Low INR It is particularly important for low INRs found during warfarin therapy to be covered with LMWH until INR>2 in the first 2 weeks from diagnosis of DVT but advisable to cover in first 6 weeks. After this, LMWH is not necessary but appropriate adjustment of warfarin dose and re-check is required Patient needs to be given either; Page 4 of 8

5 LMWH i.e. Enoxaparin (Clexane) 1.5mg/kg every 24 hours Tinzaparin (Innohep) 175units/kg every 24 hours stop when INR>2 We are unable to give advice regarding the use of NOACs during warfarin therapy to cover a dip in INR below 2 as there are currently no guidelines to which we can refer, and this is not a licensed use. Discuss with haematology before anticoagulation is initiated in the following situations: Low platelets Known bleeding disorder Previous allergy to Warfarin / LMWH Consider Rivaroxaban for all adult (non-pregnant) patients unless there are any of the following exclusions Exclusion criteria for Rivaroxaban: Liver/hepatic disease Kidney disease Renal impairment; serum creatinine > 150 micromol/l (Creatinine clearance <15 ml/min) Previous severe bleeding Uncontrolled hypertension Recent GI ulcer, oesophageal varices, recent brain or spine or ophthalmic surgery Known active cancer Concomitant use with other anticoagulant Taking some HIV medication Taking systemic azole antimycotics Drug interactions for Rivaroxaban: Phenytoin, Carbamazepine, Phenobarbital or St Johns Wort Do NOT prescribe Rivaroxaban for patients taking any of the above drugs Contraindications for LMWH: Acute bacterial endocarditis active major bleeding and conditions with a high risk of uncontrolled haemorrhage, including recent haemorrhagic stroke, active gastric or duodenal ulceration hypersensitivity to either enoxaparin sodium, heparin or its derivatives including other Low Molecular Weight Heparins Previous history of HITT (heparin induced thrombocytopenia) requires discussion with a haematologist before any anticoagulation is initiated Exclusion criteria for Warfarin: Liver disease Alcoholism active major bleeding and conditions with a high risk of uncontrolled haemorrhage, including recent haemorrhagic stroke Drug interactions for Warfarin: See, Globalrph.com Consider these before prescribing Warfarin in regards to the size of dose, treatment duration etc References: DVT, PE & IPOC V3, Nov 2013 Doncaster and Bassetlaw Hospitals 20 Patient information Patients having anticoagulation therapy should be given information about: how to use anticoagulants duration of treatment Page 5 of 8

6 possible side effects and what to do about them when and how to seek medical help BNSSG Anticoagulation choices Feb 13 Alert cards and booklet should be provided to patients taking anticoagulants Synthetic alternatives should be offered if patients are concerned about heparins of animal origins Advice about application and duration of compression stockings should be given For the full list see NICE guidance 21 Stockings Below-knee graduated compression stockings: Refer ALL patients with proximal DVT for Class 2 below-knee graduated compression stockings (specify ankle pressure >23 mmhg) 1 week after diagnosis, to allow the resolution of acute swelling. Stockings should be worn for at least 2 years and replaced 2-3 times / year. Stockings should be worn day and night until mobility is regained, then during the day only. Community pharmacy should be able to help with sizing References: National Institute for Health and Clinical Excellence (NICE). Venous thromboembolic diseases. Clinical guideline CG144. London: NICE; Rivaroxaban patients Patients need to be reviewed at 3 weeks to change to once daily dosing rivaroxaban and review whether graduated support stocking has been supplied - stocking will often need to be re-fitted at this point anyway, as swelling goes down 24 Follow up phone call (within 2 days) by GP Follow up phone call (within 2 days) to ensure that the patient is taking the medication and arranges the collection of the new script before 21 days. If patient is in secondary care then there should be communication with the GP about diagnosis and duration of treatment 26 3 week review and possible re-fit Stocking will often need to be re-fitted at this point, as swelling goes down 27 3 week review for Rivaroxaban patients Patients need to be reviewed at 3 weeks to change to once daily dosing rivaroxaban and review whether graduated support stocking has been supplied - stocking will often need to be re-fitted at this point anyway, as swelling goes down 28 Once stable or 5 days LMWH discharge back to GP to monitor GP monitors patient and gives patient education Page 6 of 8

7 Add to GP practice INR star system Page 7 of 8

8 Key Dates Published: 17-Jul-2015, by North Somerset CCG Valid until: 18-Jul-2017 Page 8 of 8