Suspected Deep Vein Thrombosis (DVT) Pathway for Non Pregnant patients Updated November 2016, with new D-dimer reference range Suspect a DVT? Complete a Two-level DVT Wells score on ICE system (see page 2) EITHER (ensure baseline FBC,U&E, LFT, INR normal in past 3m) Check D LFT, Calcium, FBC, Clotting Screen Cost e.g 100mg/ml syringe= 8/syringe NOAC: Rivaroxaban 15mg BD with food (Pk 14) *Caution: egfr <30ml/min, active cancer, pregnancy, compliance, severe liver disease Cost = 25.20/pack 14 Inform OOH if sample taken in Primary Care settling using the OOH DVT Order ultrasound leg on ICE by clicking on VTE box on the front page (ensure patient contact info is correct) D-dimer <0.25ugFEU/ml D-dimer >0.25ugFEU/ml NB if the patient has acute symptoms and whole leg involvement but a neg scan, they must stay on LMWH/ NOAC as Duplex scan can sometimes miss a high level DVT and further imaging may be needed Negative or Equivocal (see NB box) Radiographer to give patient a Negative Scan Information Leaflet (Appendix 2) Fax Scan result to referrer* and give patient a Positive Scan Information Leaflet (Appendix 3) *Referrer = GP, ED, OOH, Ward, Outpatients If the patient is pregnant the referrer should contact the on call Obstetric team. For patients with suspected PE or extending iliofemoral DVT contact AAU *NOAC: if patient is to continue then use up 15 mg b.d. for 21 day treatment ( supply from the GP ) and the remainder of the three week course issued by the anticoagulation clinic e.g. 15mg b.d. (pack 28). Then 20mg o.d. for the remainder of the treatment as advised by the anticoagulation clinic. The clinic will advise the patient s GP when to commence 20mg ppapage once daily 5 of 5 treatment dose.
Two level Wells score for Deep Vein Thrombosis (DVT) Active Cancer (treatment ongoing, within 6 months or palliative) 1 Paralysis, paresis or recent plaster immobilisation of the lower extremities 1 Recently bedridden for 3 days or more or major surgery within 12 wks requiring general or 1 regional anaesthesia Localised tenderness along the distribution of the deep venous system 1 Entire leg swollen 1 Calf swelling at least 3 cm larger than the asymptomatic side 1 Pitting oedema confined of symptomatic leg 1 Collateral superficial veins (non---varicose) 1 Previously documented DVT 1 An alternative diagnosis* is at least as likely as a DVT ---2 DVT likely if 2 points of more DVT unlikely if score is 1 point or less *Alternative Diagnosis Alternative diagnoses include: Cellulitis Superficial thrombophlebitis Ruptured Popliteal cyst Haematoma in muscle Muscle tear or strain Dependent (stasis) oedema Post---thrombotic syndrome Lymphatic obstruction Arthritis Heart failure, cirrhosis or nephrotic syndrome External compression of major veins e.g. by foetus or cancer Arterio---venous fistula Superficial thrombophlebitis Patients with extensive superficial thrombophlebitis, where the risk of deep vein thromboembolism is high, should be considered for full anticoagulation. If this is necessary and there is no contra---indication, full anticoagulation should be given for 30 days with therapeutic Clexane, warfarin or NOAC (Rivaroxaban 21 day). High risk of DVT in superficial thrombophlebitis Superficial thrombophlebitis extending to the junction of the long saphenous vein with the femoral vein. Superficial thrombophlebitis extending to the junction of the short saphenous vein with the deep veins at the crease behind the knee Past history of a VTE Patients with limited superficial thrombophlebitis can be treated with: Non---Steroidal anti---inflammatory drugs (NSAIDs) topical or oral Painkillers Treatment should continue until pain and redness have settled (usually within 2---6 wks although the thrombosed vein may be palpable and tender for months) There is only weak evidence that oral / topical NSAID reduce the risk of extension and or recurrence of superficial thrombophlebitis Contacts regarding the DVT pathway General Practitioners: Dr Nicola Decker 07708023269 (NHCCG) nicoladecker@nhs.net Haematology: Dr Tamara Everington tamara.everington@hhft.nhs.uk Radiology: Dr Clive Vandervelde clive.vandervelde@hhft.nhs.uk Reference: NICE clinical guideline CG144 (2012) Page 2 of 5
Appendix 1 Possible Deep Vein Thrombosis (DVT) Patient Information Sheet There is a small chance that you may have a DVT, based on your symptoms and an examination by your doctor. Please contact your doctor if you experience: Increased pain or swelling in the leg Sudden onset of breathlessness that is unusual Coughing or spitting up blood Any episodes of collapse or dizziness Fast heart rate, racing pulse or palpitations Please delete as appropriate: You have been prescribed a daily injection of Clexane (enoxaparin), which is a blood thinning agent. You have been prescribed an oral anticoagulant: Rivaroxaban 15mg twice a day. This is given until we know for certain whether or not you have a DVT. Your doctor will arrange an ultrasound scan as this is the best way of seeing a DVT. This should be done within the next day or two. If the scan confirms a DVT you will be referred to the anticoagulation team to continue on blood thinning treatment for a recommended period of time. If the scan is negative you can stop treatment but you must arrange to see your GP if your symptoms haven't improved. In some people the scan result will be uncertain and further tests may be needed. Appendix 2 Duplex Ultrasound Scan Report: Scan negative The scan you have had today shows no evidence of a Deep Vein Thrombosis. If your symptoms persist please contact your GP. Duplex Ultrasound Scan Report: Scan equivocal The scan you have had today is not conclusive. Please contact your GP to discuss your symptoms as you may need to have a follow up scan. Page 3 of 5
Appendix 3 Duplex Ultrasound Scan Report: Scan positive The scan you have had today confirms that you have a Deep Vein Thrombosis. The Doctor who requested the scan has been informed of the result. You will now be referred directly to the anticoagulation service. Please ask the radiologist or sonographer who performed your scan for details of where and when to go for this. Please ensure you continue to have further doses of Clexane every 24 hours or oral anticoagulants until you are on the correct dose of oral anticoagulation tablets. If you are currently an inpatient then the Doctors on your ward will organise your anticoagulation initially and will explain what will happen next. Follow up for Confirmed DVT (by the Referrer) Please consider hospital admission if the patient is unwell or otherwise unsuitable for ambulatory care. Rivaroxaban: 15mg twice daily for 3 weeks, and then 20mg once daily for the remainder of the treatment, and does not require frequent dose adjustment. Counsel the patient to take Rivaroxaban regularly and with food. o After 3 weeks then 20mg o.d. for the remainder of the treatment. The clinic will advise the patient s GP when to commence 20mg once daily treatment dose. Clexane should be given until the patient is fully anticoagulated with an oral agent. Do not use more than 1 dose of Clexane if patient has an egfr < 30ml/min (discuss with consultant on call). FBC must be checked at baseline, on day 4 and between Days 7 and 10 in all patients with cancer continuing on Clexane to look for a fall in platelet count which might herald heparin induced thrombocytopenia with thrombosis (HITT). A > 50% fall in platelet count from baseline must be discussed with a Haemophilia consultant. Please check baseline FBC, U&E, LFTs and a full coagulation screen if there are no results within the last 3 months and / or there has been significant clinical change since the last tests. Underlying causes for an unprovoked above knee DVT must be considered. A general health screen and basic blood / urine testing (if not done already) should be performed by the GP. If there are any features which raise suspicion of underlying malignancy or other serious pathology then targeted testing should be done. This may include CXR, USS and a mammogram in women. If CT may be preferred or the event was unprovoked referral to the haemophilia consultant is advised for further investigation*. GP to offer below knee graduated compression stocking with an ankle pressure of > 23mmHg to patients with a proximal DVT a week after diagnosis or when swelling is reduced sufficiently and if there are no contraindications. Advise patients to continue Page 4 of 5
wearing the stocking for at least 2 years, to ensure that the stockings are replaced 2 to 3 x / year and advise patients that the stocking needs to be worn only on the affected leg(s). If you need to speak to the Anticoagulation team call 01256 314793 Mon to Fri 9am to 5pm or 01256 473202 and ask for Haemophilia Consultant on call. *Discussion with a consultant radiologist or physician is advisable and helpful when arranging the necessary investigations Note on New treatments for DVT Recently we agreed to add Rivaroxaban (novel oral anticoagulant (NOAC) or Direct Oral Anticoagulant (DOAC)) as an option for the treatment of DVT. Warfarin with Enoxaparin remains an option where a NOAC/ DOAC is not suitable. Rivaroxaban is one of the newer anticoagulant agents and is a Factor Xa inhibitor. It offers some real advantages to patients over Warfarin therapy, but it is not suitable for everyone. The main advantages to the patient are: It does not require bridging with Enoxaparin in the same way as Warfarin, hence patients do not need to have injections. Once it is started orally it is fully active rapidly. It does not require frequent monitoring like warfarin, so patients need far fewer blood tests. It is a relatively simple dosing regimen 15mg b.d. for 3 weeks, and then 20mg o.d. for the remainder of the treatment, and does not require frequent dose adjustment. Rivaroxaban must be taken with food. It has much fewer drug interactions with warfarin. However, it does not suit everyone, and we exclude the following groups: o Patients with an egfr of <30mls/min o Active cancer o Pregnancy o Compliance issues it is difficult to monitor compliance o Severe liver disease In patients who meet the exclusion criteria we would still manage either with Enoxaparin and Warfarin, or Enoxaparin alone. What do I do if my patient bleeds on one of the new agents? One of the major concerns about many novel oral anticoagulants (NOACs) is that there is no currently available reversal agent for its effects, unlike warfarin (vitamin K and prothrombin concentrates), heparin (protamine) or Dabigatran. If you have a patient with minor bleeding in the community then the best course of action is to stop the drug until the bleeding problem is resolved. The drugs have a relatively short half-life, and stopping them is likely to resolve most issues. If there is severe bleeding then the patient should be directed to the appropriate specialty within HHFT as an emergency. Page 5 of 5