Tratamento da trombose venosa profunda

Treatment:

if home circumstances are adequate, initial treatment at home recommended over treatment in hospital

indications for inpatient management

• massive DVT
  

• symptomatic pulmonary embolism (PE)
  

• high risk of bleeding with anticoagulant therapy
  

• comorbid conditions
  

consider thrombolytic therapy in very rare complication of impending venous gangrene

early ambulation after DVT suggested over initial bed rest and does not appear harmful

initial parenteral anticoagulation recommended with any of the following regimens (for at least 5 days and until INR ≥ 2 for 24 hours if also starting vitamin K antagonist [VKA])

• subcutaneous low-molecular-weight heparin (LMWH)
  

enoxaparin (Lovenox) 1 mg/kg subcutaneously every 12 hours for inpatient or outpatient management
enoxaparin (Lovenox) 1.5 mg/kg subcutaneously once daily for inpatient management
tinzaparin (Innohep) 175 units/kg subcutaneously once daily

• fondaparinux (Arixtra) 5-10 mg subcutaneously once daily based on weight
  

• IV unfractionated heparin (UFH)
  

initial IV bolus 80 units/kg or 5,000 units
subsequent continuous infusion with initial dose 18 units/kg/hour or 1,000 units/hour

• subcutaneous UFH
  

initial dose 333 units/kg
subsequent dose 250 units/kg twice daily

selection of initial anticoagulation

• LMWH or fondaparinux suggested over IV UFH  and over subcutaneous UFH
  

fixed-dose LMWH appears to reduce mortality, thrombotic complications, and major hemorrhage compared to adjusted-dose UFH for initial treatment of venous thromboembolism (VTE)
fondaparinux appears as safe and effective as heparins for initial treatment of VTE
subcutaneous UFH might have higher risk of recurrent DVT than other options

• if treated with LMWH, once-daily dosing might be as safe and effective as twice-daily dosing for initial treatment
  

• if renal impairment use UFH or use other agents with monitoring; reduce dose if using LMWH and creatinine clearance < 30 mL/minute
  

continuation of anticoagulation

• for long-term treatment of DVT suggested anticoagulant is VKA in patients without cancer and LMWH in patients with cancer
  

compared to oral VKA for long-term treatment, LMWH appears as safe and effective in patients without cancer  and may have lower VTE recurrence risk in patients with cancer
dabigatran is as effective as warfarin following parenteral anticoagulation for VTE, but associated with increased risk for myocardial infarction

• for starting VKA therapy
  

starting VKA early (same day as parenteral anticoagulation) recommended
initial dosing with warfarin 10 mg once daily for 2 days, then dosing based on INR measurements
target INR 2.5 (INR 2-3) recommended

• longer duration of anticoagulation decreases risk of recurrent VTE
  

if transient risk factor (surgical or nonsurgical), anticoagulation for 3 months recommended
if unprovoked DVT: anticoagulation for 3 months recommended if high bleeding risk; extended anticoagulant therapy suggested if low or moderate bleeding risk
if active cancer, extended anticoagulant therapy recommended
anticoagulation duration tailored for residual thrombosis may reduce recurrent VTE in patients with proximal DVT

oral factor Xa inhibitors can be used for both initial and long-term anticoagulation

• rivaroxaban (Xarelto) appears as effective as enoxaparin plus VKA for treatment of DVT
  

• apixaban (Eliquis) is at least as effective for treatment of acute venous thromboembolism as conventional therapy and reduces bleeding risk
  

elastic compression stockings

• may not reduce risk of postthrombotic syndrome
  

• suggested by guidelines, but these guidelines were published before large blinded randomized trial was published
  

Referência:
Deep vein thrombosis (DVT) - Treatment overview. In DynaMed [database online]. EBSCO Information Services. http://web.ebscohost.com/dynamed/detail?vid=4&sid=b04e14f7-1ee9-485a-8971-ccc25e9b578c%40sessionmgr114&hid=106&bdata=Jmxhbmc9cHQtYnImc2l0ZT1keW5hbWVkLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#db=dme&AN=133588&anchor=Treatment. Atualizado em 25 de Março de 2015. Acessado em 14 de Abril de 2015.