Well's scoring / criteria
Present | Score |
---|---|
Paralysis, paresis or immobilisation in a plaster cast | +1 |
Bed ridden (> 3/7) or surgery within the last 4/52 | +1 |
Tenderness along line of femoral or popliteal veins (NOT just calf tenderness) | +1 |
Entire limb swollen | +1 |
Calf >3cm bigger circumference, 10cm below tibial tuberosity | +1 |
Pitting oedema greater in symptomatic limb | +1 |
Dilated collateral superficial veins (on-varicose) | +1 |
Past Hx of confirmed DVT | +1 |
Malignancy (incl. treatment within 6 months) | +1 |
Alternative diagnosis is more likely than DVT | -2 |
Rivaroxaban Special populations
Renal impairment
- Xarelto is to be used with caution in these patients
- Please check BNF or medicines.ie
Hepatic impairment
- Rivaroxaban is contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk including cirrhotic patients with Child Pugh B and C.
Elderly population
- No dose adjustment
Body weight
- No dose adjustment
Gender
- No dose adjustment
Children
- Xarelto is not recommended for patients <18 years
DDx
- Baker's cyst
- Cellulitis
- Superficial venous thrombosis
- Popliteal art pathology
- Inguinal lymphadenopathy/proximal mass
- External venous compression
- Post-phlebitic (-thrombotic) syndrome
- Proximal abscess (esp. in IVDU)
- Gout
- Lymphoedema
- Oedema of cardiac/hepatic/renal failure
- Trauma (e.g. muscle injury, fracture)
Not suitable for home treatment
- Unable to walk, frail or in severe pain
- Unable to understand the instructions
- Unable to understand the importance of compliance with the treatment
- Unable to return for the scan next morning - if awaiting scan
Bleeding risk:
- Liver disease
- active peptic ulcer
- alcohol abuse
Management Proven VTE
Provoked leg DVT
Anticoagulate for 3 months.
Unprovoked DVT
Increased risk of occult malignancy so:
- Ask about personal or family history of malignancy and symptoms concerning for underlying malignancy e.g. weight loss, bleeding, altered bowel habit etc
- A thorough physical exam: including breast and PR
- Ensure age appropriate screening is up to date
- Check FBC, ESR, LFT, U&E, CXR, Ca++, urinalysis and CXR
- Men > 40 - request PSA
- The need for further investigation (endoscopy, imaging etc.) should be guided by findings from the history and exam and results from the initial blood tests (ISTH 2017, NICE 2020)
Isolated calf DVT
For high risk (e.g. cancer) patients, or very symptomatic patients, - treat with Rivaroxaban 15mg bd po day 1-21 then Rivaroxaban 20mg od po day 22+) for 3 months.
For low risk patients who are mildly sympomatic, please discuss with the patient. Anticoagulation reduces the incidence of clot propagation, clot recurrence (3% vs. 9% Cochrane [below] NNT = 16) and the need for re-scan but increases the risk of bleeding and means taking tablets each day for 3 months. Anticoagulation does not reduce the incidence of PE with isolated calf DVT.
If you and the patient jointly decide to not anticoagulate, please ask the patient to return for a rescan in 1-2 weeks (15% propagate).
Thrombophilia screen in OPD, not ED
In CUH, a thrombophilia screen may be requested by the haematology team using a specific consent form (print version on https://www.cuh.hse.ie/our-services/our-specialities-a-z-/laboratory-medicine/services-provided/downloads/cuh-thrombophilia-screen-request-form.pdf).
Considered in those
- Patients with a known FHx of thrombophilia
- Under 45 years old with VTE, no ppt cause
- Recurrent thromboses
- Thrombosis in an unusual site
- FHx of thrombosis or
- FHx of recurrent (2 or more) VTE
- Past Hx of of recurrent foetal loss
Request
- Antithrombin
- Protein S, Protein C
- APC resistance
- Factor V Leiden mutation
- Lupus anticoagulant
- Anticardiolipin antibodies
Br J Haematol 2010: 149 (2) 209-220 Clinical guidelines for testing for heritable thrombophilia (www.bcshguidelines.com)
Links
- Arm DVT
- Patient advice sheet re home anticoagulation
- IAEM Guideline Lower Limb DVT (2021)
- Rivaroxaban page
- DOACs info. Please check for interactions before initiating treatment. Please consult Haematology if NOAC is contraindicated with any existing medication
- Cochrane review "Treatment of distal deep vein thrombosis" 09 April 2020 (https://doi.org/10.1002/14651858.CD013422.pub2), George KirkilesisStavros K KakkosColin BicknellSafa SalimKyriaki Kakavia