Suggested anticoagulant therapy for the acute-phase treatment
| Symptom . | Treatment . |
|---|---|
| Noncirrhotic, symptomatic SVT patients with no signs of active bleeding | Consider full therapeutic dose LMWH (eg, 1 mg/kg twice daily). Start VKA after 48-72 h if no bleeding occurs. |
| Cancer-associated SVT | Full therapeutic dose LMWH (eg, 1 mg/kg twice daily) for 1 mo and then reduce to 75% of the initial dose for at least 3–6 mo. |
| Estimated glomerular filtration rate <30 mL/min | Consider UFH or reduce the dose of LMWH by 50% and consider anti-Factor Xa level monitoring. If creatinine clearance is lower than 15 mL/min, abstain from using LMWH. VKA should be started as soon as possible to reduce the duration of heparin treatment (consider VKA also for cancer patients with chronic severe renal insufficiency). |
| Platelet count >30 000 and <50 000 per mm3 | Reduce the dose of LMWH by at least 50%, (more if additional risk factors for bleeding are present) and delay VKA initiation (if VKA is indicated) until the cause of thrombocytopenia is diagnosed and managed. Consider abstaining from anticoagulant therapy if a single vessel clot with limited extension and reassess when platelet count improves. |
| Platelet count <30 000 per mm3 | Abstain from using anticoagulant drugs or consider prophylactic dose LMWH if acute thrombosis in multiple vessels and platelet count more than 20 000 per mm3. |
| Cirrhotic, symptomatic PVT patient | Consider full therapeutic dose LMWH (eg, 1 mg/kg twice daily) after careful assessment (and treatment, if necessary) of esophageal varices. Empiric dose reductions (50% of therapeutic dose or more, based on individual risk assessment) if additional risk factors for bleeding are identified. Delay starting of LMWH if major risk factors for bleeding coexist, until successfully managed. Delay VKA initiation and start only when the patient is stable and no additional major bleeding risk factors are identified, also according to patient preference. |
| Concomitant renal failure | Same as for the noncirrhotic patient, but consider abstaining from any anticoagulant treatment if poor short-term prognosis or if concomitant major risk factors for bleeding are identified. VKA is to be considered if no severe concomitant coagulopathy exists. |
| Platelet count <50 000 per mm3 | Abstain from anticoagulant treatment or reduce the dose of LMWH by 50% (or more, based on individual risk assessment) if extended and occlusive thrombosis. |
| Incidentally detected SVT | Apply the same treatment regimens proposed for the symptomatic patient unless 1 or more of the following conditions are identified: thrombosis is nonocclusive, likely not recent, and limited to a single vein segment; no permanent risk factors or no recent (<1 mo) removable risk factors for thrombosis are identified; bleeding risk is moderate to high; and prognosis of underlying disease is poor. |
| Symptom . | Treatment . |
|---|---|
| Noncirrhotic, symptomatic SVT patients with no signs of active bleeding | Consider full therapeutic dose LMWH (eg, 1 mg/kg twice daily). Start VKA after 48-72 h if no bleeding occurs. |
| Cancer-associated SVT | Full therapeutic dose LMWH (eg, 1 mg/kg twice daily) for 1 mo and then reduce to 75% of the initial dose for at least 3–6 mo. |
| Estimated glomerular filtration rate <30 mL/min | Consider UFH or reduce the dose of LMWH by 50% and consider anti-Factor Xa level monitoring. If creatinine clearance is lower than 15 mL/min, abstain from using LMWH. VKA should be started as soon as possible to reduce the duration of heparin treatment (consider VKA also for cancer patients with chronic severe renal insufficiency). |
| Platelet count >30 000 and <50 000 per mm3 | Reduce the dose of LMWH by at least 50%, (more if additional risk factors for bleeding are present) and delay VKA initiation (if VKA is indicated) until the cause of thrombocytopenia is diagnosed and managed. Consider abstaining from anticoagulant therapy if a single vessel clot with limited extension and reassess when platelet count improves. |
| Platelet count <30 000 per mm3 | Abstain from using anticoagulant drugs or consider prophylactic dose LMWH if acute thrombosis in multiple vessels and platelet count more than 20 000 per mm3. |
| Cirrhotic, symptomatic PVT patient | Consider full therapeutic dose LMWH (eg, 1 mg/kg twice daily) after careful assessment (and treatment, if necessary) of esophageal varices. Empiric dose reductions (50% of therapeutic dose or more, based on individual risk assessment) if additional risk factors for bleeding are identified. Delay starting of LMWH if major risk factors for bleeding coexist, until successfully managed. Delay VKA initiation and start only when the patient is stable and no additional major bleeding risk factors are identified, also according to patient preference. |
| Concomitant renal failure | Same as for the noncirrhotic patient, but consider abstaining from any anticoagulant treatment if poor short-term prognosis or if concomitant major risk factors for bleeding are identified. VKA is to be considered if no severe concomitant coagulopathy exists. |
| Platelet count <50 000 per mm3 | Abstain from anticoagulant treatment or reduce the dose of LMWH by 50% (or more, based on individual risk assessment) if extended and occlusive thrombosis. |
| Incidentally detected SVT | Apply the same treatment regimens proposed for the symptomatic patient unless 1 or more of the following conditions are identified: thrombosis is nonocclusive, likely not recent, and limited to a single vein segment; no permanent risk factors or no recent (<1 mo) removable risk factors for thrombosis are identified; bleeding risk is moderate to high; and prognosis of underlying disease is poor. |