Well's scoring / criteria

Present Score
Paralysis, paresis or immobilisation in a plaster cast +1
Bed ridden (> 3/7) or surgery within 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 Dx 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


  • No dose adjustment


  • Xarelto is not recommended for patients <18 years

Leg injuries/immobilisation


  • 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 FHx 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)
  • For those already antiocaogulated, who develop a DVT, please discuss with haematology re home management (haematology follow up) with therapeutic LMWH

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


  • 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)

Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS, Regina Lee (Pharmacist CUH), Dr Rory O'Brien, Dr ÍOS 29/04/24.