DVT



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)



Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS, Regina Lee (Pharmacist CUH), Dr Rory O'Brien, Dr ÍOS 6/10/21.