Venous Thromboembolism: Anticoagulation

Venous Thromboembolism: Anticoagulation: overview

This algorithm covers anticoagulation for acute venous thromboembolism (deep vein thrombosis or pulmonary embolism), branching by patient population and special situations.

For most patients, a direct oral anticoagulant (DOAC) is preferred, with apixaban (AMPLIFY) and rivaroxaban (EINSTEIN) shown as the main options. For cancer-associated VTE, either a DOAC or low-molecular-weight heparin (LMWH) is appropriate, supported by Hokusai-Cancer. Special situations favor warfarin (a vitamin K antagonist): antiphospholipid syndrome and severe renal impairment, with DOACs specifically avoided in triple-positive antiphospholipid syndrome. Duration of therapy is the other key decision: 3 months for provoked events, versus extended anticoagulation when the event was unprovoked or the risk factor is ongoing. The chart therefore separates agent selection, driven by cancer status, renal function and antiphospholipid syndrome, from duration, driven by whether the event was provoked.

Trials behind this algorithm

AMPLIFY (VTE) Agnelli G et al, NEJM, 2013; PMID: 23808982
EINSTEIN-DVT Bauersachs R et al, NEJM, 2010; PMID: 21128814
Hokusai-VTE Büller HR et al, NEJM, 2013; PMID: 23991658

Background reading: Thrombophilias and VTE management board review notes.

Venous Thromboembolism: Anticoagulation: the algorithm in words

Starting point: Acute VTE (DVT / PE). Full background: Thrombophilias and VTE management notes.

Most patients (first-line): Preferred: DOAC: apixaban (AMPLIFY); Preferred: DOAC: rivaroxaban (EINSTEIN).
Cancer-associated (first-line): Onc VTE: DOAC or LMWH (Hokusai-Cancer).
Special situations (second-line): APS / severe renal: Warfarin (VKA) (avoid DOAC in triple-+ APS); Duration: 3 mo (provoked) vs extended (if unprovoked / ongoing risk).