Use DOACs first line for acute VTE treatment, new guidelines advise

A recommendation to use a factor Xa inhibitor first line for the treatment of acute VTE is one of the key features of new Australasian guidelines.

Released by Thrombosis and Haemostasis Society of Australia and New Zealand (THANZ) this week, the new guidelines recommend that most patients with acute VTE should be treated with an oral factor Xa inhibitor such as apixaban and rivaroxaban, which are preferred to dabigatran or warfarin to treat proximal DVT and PE because they do not require parenteral LMWH anticoagulation for initiation.

The guidelines also recommend that every VTE patient receives three months (6 weeks for those with distal DVT) of anticoagulation with a decision then to be made about whether to continue long-term.

Low-intensity anticoagulation over the long term is also recommended as suitable for many patients because it is both safe and effective.

The new guidelines, published in the MJA were developed by a working group led by Associate Professor Huyen Tran, Head of the Haemostasis and Thrombosis Unit at Alfred Health and Monash University in Melbourne.

Other recommendations from the guidelines include:

  • the diagnosis of VTE should be established with imaging; it may be excluded by the use of clinical prediction rules combined with D-dimer testing;
  • proximal DVT or PE caused by a major surgery or trauma that is no longer present should be treated with anticoagulant therapy for three months;
  • proximal DVT or PE that is unprovoked or associated with a transient risk factor (non-surgical) should be treated with anticoagulant therapy for 3–6 months;
  • proximal DVT or PE that is recurrent (two or more) and provoked by active cancer or antiphospholipid syndrome should receive extended anticoagulation;
  • distal DVT caused by a major provoking factor that is no longer present should be treated with anticoagulant therapy for six weeks;
  • for patients continuing with extended anticoagulant therapy, either therapeutic or low dose direct oral anticoagulants can be prescribed and is preferred over warfarin in the absence of contraindications;
  • routine thrombophilia testing is not indicated; and,
  • thrombolysis or a suitable alternative is indicated for massive (haemodynamically unstable) PE.

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