Deep Vein Thrombosis (cont.)
Benjamin Wedro, MD, FACEP, FAAEM
Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.
Melissa Conrad Stöppler, MD
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
William C. Shiel Jr., MD, FACP, FACR
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
In this Article
- Deep vein thrombosis (DVT) definition and facts
- What is DVT?
- What does a blood clot in the leg look like?
- What causes DVT?
- Signs and symptoms of DVT
- Signs and symptoms of superficial blood clots
- Who is at risk?
- Which types of doctors treat DVT?
- What tests diagnose the condition?
- What are the treatment guidelines for DVT?
- What is the treatment of superficial blood clots?
- Medications to treat blood clots in the leg
- Warfarin (Coumadin, Jantoven)
- Side effects and risks of anticoagulation therapy
- Does DVT require surgery?
- What are the complications?
- How can blood clots in the legs be prevented?
- Deep Vein Thrombosis and Pulmonary Embolism FAQs
- Find a local Cardiologist in your town
What are the treatment guidelines for DVT?
The treatment for deep venous thrombosis is anticoagulation or "thinning the blood" with medications.
The recommended length of treatment for an uncomplicated DVT is three months. Depending upon the patient's situation, underlying medical conditions and the reason for developing a blood clot, a longer duration of anticoagulation may be required. At three months, the doctor or other health care professional should evaluate the patient in regard to the potential for future blood clot formation. If the decision is made to continue anticoagulation over the long term, the risk/reward decision of preventing clots versus bleeding risk should occur every year to decide if anticoagulation is still a reasonable treatment.
There are times when anticoagulation may have increased bleeding risk, for example, if the patient has had recent major surgery (anticoagulation thins all of the blood in the body not just the DVT). Other bleeding risks occur in patients with liver disease and those who take medications that can interact with the anticoagulation medicines.
What is the treatment of superficial blood clots?
Treatment for superficial thrombophlebitis treating the symptoms with:
- Warm compresses
- Leg compression
- Anti-inflammatory medications such as ibuprofen (Mortin) or naproxen (Naprocen).
If the thrombophlebitis occurs near the groin where the superficial and deep systems join together, there is potential that the thrombus could extend into the deep venous system. These patients may require anticoagulation or blood thinning therapy.
Medications to treat blood clots in the leg
Anticoagulation prevents further growth of the blood clot and prevents it from forming an embolus that can travel to the lung. The body has a complex mechanism to form blood clots to help repair blood vessel damage. There is a clotting cascade with numerous blood factors that have to be activated for a clot to form. There are difference types of medications that can be used for anticoagulation to treat DVT:
- Unfractionated heparin
- Low molecular weight heparin: enoxaparin (Lovenox)
- Novel oral anticoagulatants (NOACs) also known as direct oral anticoagulants (DOACs)
- Warfarin (Coumadin, Jantoven)
The American College of Chest Physicians has guidelines that give direction as to what medications might best be used in different situations. For example, a patient with a DVT, and no active cancer, treatment with a NOAC would be recommended. If active cancer exists, the treatment of DVT would be with enoxaparin as the drug of first choice.
NOACs work almost immediately to thin the blood and anticoagulate the patient. There is no need for blood tests to monitor dosing. The NOAC medications presently approved for deep vein thrombosis treatment include:
- apixaban (Eliquis)
- rivaroxaban (Xarelto)
- edoxaban (Savaysa)
- dabigatran (Pradaxa)
Warfarin (Coumadin, Jantoven)
Warfarin (Coumadin, Janotven) is an anti-coagulation medication that acts as a Vitamin K antagonist, blocking blood clotting factors II, VII, IX and X. Historically, it was a first-line medication for treating blood clots, but its role has been diminished because of the availability of newer drugs. While warfarin may be prescribed immediately after the diagnosis of DVT, it takes up to a week or more for it to reach therapeutic levels in the blood so that the blood is appropriately thinned. Therefore, low molecular weight heparin (enoxaparin [Lovenox)] is administered at the same time. Enoxaparin thins the blood almost immediately and is used as a bridge therapy until the warfarin has taken effect. Enoxaparin injections can be given on an outpatient basis. For those patients who have contraindications to the use of enoxaparin (for example, kidney failure does not allow the drug to be appropriately metabolized), intravenous heparin can be used as the first step in association with warfarin. This requires admission to the hospital. The dosage of warfarin is monitored by blood tests measuring the prothrombin time (PT), or INR (international normalized ratio).
Side effects and risks of anticoagulation therapy
Patients who take anticoagulation medications are at risk for bleeding. The decision to use these medications must balance the risk and rewards of the treatment. Should bleeding occur, there are strategies available to reverse the anticoagulation effects.
Some patients may have contraindications to anticoagulation therapy, for example a patient with bleeding in the brain, major trauma, or recent significant surgery. An alternative may be to place a filter in the inferior vena cava (the major vein that collects blood from both legs) to prevent emboli, should they arise, from reaching the heart and lungs. These filters may be effective but have the potential risk of being the source of new clot formation. An IVC filter is NOT recommended for patients who are also taking anticoagulation medications.
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