This site is intended for health professionals only

At the heart of general practice since 1960

Read the latest issue online

Gold, incentives and meh

Managing DVT

Anticoagulants are used for the treatment of DVT/PE, to prevent recurrence, and to reduce the risk of secondary complications such as post-thrombotic syndrome (PTS) and chronic thromboembolic pulmonary hypertension (CTEPH).1,2

The phases of anticoagulation treatment may be categorised as initial, long-term (or continued) and extended.3 The first two phases are considered as active treatment and secondary prevention, whereas the extended phase is secondary prevention only.4

Phases of anticoagulation treatment for DVT4–9

Anticoagulation Treatment

Adapted from Kearon et al., 2012.
Initial treatment with ELIQUIS is for 7 days and 21 days for rivaroxaban.
* Heparin, LMWH, fondaparinux. Initial therapy may be with oral rivaroxaban or apixaban.
† Includes LMWH and NOACs.

[References for image: 4. Kearon C. J Thromb Haemost 2012; 10: 507–511. 5. Kearon C. Chest 2012; 141: (2 Suppl). 6. Apixaban Summary of Product Characteristics. Accessed August 2019. Available at: https://www.medicines.org.uk/emc/product/2878/smpc. 7. Dabigatran Summary of Product Characteristics. Accessed August 2019. Available at: https://www.medicines.org.uk/emc/product/4703/smpc. 8. Edoxaban Summary of Product Characteristics. Accessed August 2019. Available at: https://www.medicines.org.uk/emc/product/6906/smpc. 9. Rivaroxaban Summary of Product Characteristics. Accessed August 2019. Available at: https://www.medicines.org.uk/emc/product/2793/smpc.]

Guidelines for managing VTE

Traditionally, low molecular weight heparin (LMWH) is used for the initial treatment phase and VKA for the long-term continued treatment phase. VKA is used for the extended phase after assessing the risks and benefits of continuing anticoagulation. NICE and SIGN guidelines for the management of VTE, which were last updated in 2015 and 2014, respectively, recommend this approach.10,11

Following the initial publication of these guidelines, four NOACs have been approved for the treatment and secondary prevention of VTE in adults.6–9 Apixaban and rivaroxaban may be used for initial and long-term treatment, and secondary prevention, whereas dabigatran and edoxaban may be used for long-term treatment and secondary prevention after initial treatment with LMWH.5–8 The NOACs are now recommended, within their marketing authorisations, as options by NICE12–17 and Scottish Medicines Consortium (SMC).18–21

Of note, some international guidelines now recommend NOACs over LMWH VKAs for some patients with VTE. The ESC consensus statement for the diagnosis and management of acute DVT recommends NOACs as the preferred first-line anticoagulant therapy in (non-cancer) patients with proximal DVT.3 Similarly, the American College of Chest Physicians (ACCP) guidelines on antithrombotic therapy and prevention of thrombosis suggest NOACs should be used in preference to VKA therapy for the long-term (first 3-months) treatment of (non-cancer) patients with DVT of the leg or PE.22

More information on anticoagulants for the treatment and secondary prevention of VTE is provided later.




In Managing VTE: Managing VTE | The signs and symptoms of VTE | How do I diagnose DVT? | What information and support can I give to my patients?

Click here to view ELIQUIS (apixaban) prescribing and adverse event reporting information.

Abbreviations

ACCP = American College of Chest Physicians CTEPH Chronic Thromboembolic Pulmonary Hypertension DVT = Deep Vein Thrombosis LMWH = Low Molecular Weight Heparin NICE = National Institute for Health and Care Excellence NOAC = Non-vitamin K antagonist Oral Anticoagulant PE = Pulmonary Embolism PTS = Post-Thrombotic Syndrome SIGN = Scottish Intercollegiate Guidelines Network SMC = Scottish Medicines Consortium VKA = Vitamin K Antagonist VTE = Venous Thromboembolism

References
  1. Lang IM et al. Circulation 2014; 130: 508–518.
  2. Farrell JJ et al. Cardiovasc Diagn Ther 2016; 6: 623–631.
  3. Mazzolai L et al. Eur Heart J 2018; 39: 4208–4218.
  4. Kearon C. J Thromb Haemost 2012; 10: 507–511.
  5. Kearon C. Chest 2010; 141: (2 Suppl).
  6. Apixaban Summary of Product Characteristics. Accessed August 2019. Available at: https://www.medicines.org.uk/emc/product/2878/smpc.
  7. Dabigatran Summary of Product Characteristics. Accessed August 2019. Available at: https://www.medicines.org.uk/emc/product/4703/smpc.
  8. Edoxaban Summary of Product Characteristics. Accessed August 2019. Available at: https://www.medicines.org.uk/emc/product/6906/smpc.
  9. Rivaroxaban Summary of Product Characteristics. Accessed August 2019. Available at: https://www.medicines.org.uk/emc/product/2793/smpc.
  10. SIGN Guideline (122). Prevention and management of venous thromboembolism. October 2014. Available at: http://www.sign.ac.uk/sign-122-prevention-and-management-of-venous-thromboembolism.html?UNLID=682143975201771805243. Accessed August 2019.
  11. NICE. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (CG144). November 2015. Available at: www.nice.org.uk/guidance/cg144. Accessed August 2019.
  12. NICE Key Therapeutic Topic [KTT16]. Anticoagulants, including non-vitamin K antagonist oral anticoagulants. Available at: https://www.nice.org.uk/advice/ktt16/chapter/evidence-context. Accessed August 2019.
  13. NICE. Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism [TA341]. Available at: https://www.nice.org.uk/guidance/ta341. Accessed August 2019.
  14. NICE. Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism [TA261]. Available at: https://www.nice.org.uk/guidance/ta261. Accessed August 2019.
  15. NICE. Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism [TA287]. Available at: https://www.nice.org.uk/guidance/ta287. Accessed August 2019.
  16. NICE. Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism [TA327]. Available at: https://www.nice.org.uk/guidance/ta327. Accessed August 2019.
  17. NICE. Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism [TA354]. https://www.nice.org.uk/guidance/ta354. Accessed August 2019.
  18. SIGN Advice: apixaban (Eliquis®). Available at: https://www.scottishmedicines.org.uk/medicines-advice/apixaban-eliquis-fullsubmission-102915/. Accessed August 2019.
  19. SIGN Advice: rivaroxaban (Xarelto®). Available at: https://www.scottishmedicines.org.uk/medicines-advice/rivaroxaban-xarelto-dvt-fullsubmission-75512/. Accessed August 2019.
  20. SIGN Advice: dabigatran (Pradaxa®). Available at: https://www.scottishmedicines.org.uk/medicines-advice/dabigatran-etexilate-pradaxa-fullsubmission-99514/. Accessed August 2019.
  21. SIGN Advice: edoxaban (Lixiana®). Available at: https://www.scottishmedicines.org.uk/medicines-advice/edoxaban-lixiana-fullsubmission-109015/. Accessed August 2019.
  22. Kearon C et al. Chest 2016; 149: 315‒352.

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

YOU ARE ABOUT TO LEAVE THIS WEBSITE.

×

This link takes you to a third party website (outside of the Bristol-Myers Squibb Group and Pfizer Group). Bristol-Myers Squibb and Pfizer has no control over the content or management of third party websites nor can it be held responsible or liable for such content or management. Please make sure the contents therein are suitable for you as per its intended audience and the applicable laws and regulations. It is recommended that you carefully read the legal notice and cookies and privacy policy of third party websites before accessing these sites.

If you wish to continue, click ‘Continue’, otherwise click ‘Stay on this site’.

Continue Stay on this site

Job code: 432UK1900506-01
Date of preparation: September 2019

BMS  Pfizer stacked Logo