Dx

DVT Prophylaxis¹

Parenteral Dosing²

Drug	Dose	Adjustments	Notes
UFH	5000 Units Q8-12H	None	Higher risk of HIT
Enoxaparin	40mg SubQ QD 30mg SubQ BID	CrCl < 30: 30mg SubQ QD	Low risk of HIT
Fondaparinux	2.5mg SubQ QD	CrCl 30-50: Caution CrCl < 30: CI	Must be ≥ 50kg

PO Dosing²

Drug	Indication	Dosing	Adjustments	Notes
Rivaroxiban	THA or TKA	10mg QD x10-14d NTE 34d starting 6-10hr after surgery	CrCl 30-50: Caution CrCl < 30: CI	Use longer interval for THA, shorter end for TKA
Apixaban	THA or TKA	2.5mg BID x10-14d NTE 34d starting 12-24hr after surgery	CrCl < 30: No evidence
Dabigatran	THA	110mg x1 dose 1-4hr after surgery OR 220mg on the first day, then 220mg QD 10-14d NTE 35d	CrCl 30-50: Consider 150mg QD instead of 220mg CrCl < 30: No evidence	Times close to 30d recommended Watch w/ PGP inhibitors

At least 3mo anticoag
- PO therapy (DOAC or warfarin) preferred if no cancer
- LMWH preferred if cancer
- Generally stick to 3, low-moderate bleed risk unprovoked VTE recommend extended (no scheduled stop date)
- If DVT recurs while on anticoag, switch to LMWH or increase LMWH by 25-33% if already on LMWH
ASA is not as good as anticoag, but better than nothing
Distal DVT w/ serial imaging can forgo anticoag if thrombus does not extend

Low Risk: Tx outpatient
Thrombolysis for hemodynamic instability (SBP < 90) w/o high bleed risk
- Give thrombolytics if pt deteriorates after anticoag if low bleed risk
- Systemic over catheter directed
- Can be used in stable PE when risks outweigh benefits, but off label and not usually recommended
- Hemodynamically unstable / shock, high bleed risk, or failure of systemic thrombolysis => catheter directed removal
No thrombolysis if hemodynamically stable

Initial Parenteral Anticoag²

Drug	Dose	Adjustments
UFH	80 U/kg IVB then 18 U/kg/hr 333 U/kg SubQ then 250 U/kg Q12H	Monitor aPTT Q4-6H (titration) or Q24H (Wt based) based on protocol Goal 1.5-2x ULN
Enoxaparin	1 mg/kg SubQ Q12H 1.5 mg/kg SubQ Q24H	CrCl < 30: 1 mg/kg SubQ Q24H
Fondaparinux	< 50kg: 5mg SubQ QD 50-100kg: 7.5mg SubQ QD > 100kg: 10mg SubQ QD x5-9d	CrCl 30-50: Caution CrCl < 30: CI

PO Anticoag²

Drug	Dose	Notes
Warfarin	2.5-7.5mg PO QD initial	Start w/ parenteral anticoag until therapeutic INR Titrate based on INR (Goal 2-3)
Rivaroxaban	15mg PO BID x21d then 20mg PO QD	Must be taken w/ food No initial parenteral anticoag needed
Apixaban	10mg PO BID x7d then 5mg PO QD	No initial parenteral anticoag needed
Dabigatran	150mg PO BID	Initiate after 5d of parenteral anticoagulant Avoid if CrCl ≤ 30 (never in trials) Watch w/ PGP inhibitors
Edoxaban	> 60kg: 60mg PO QD ≤ 60kg: 30mg PO QD	Initiate after 5d of parenteral anticoagulant Do not use if CrCl > 95 or < 15 CrCl 15-50: 30mg QD

Thrombolytic Dosing²

Drug	Dose	Notes
Alteplase	100mg IV over 2hr	Check for CIs (below) Start heparin near end of infusion or when aPTT is 2x ULN
Tenecteplase (off-label)	Wt based bolus over 5 seconds (See table below)	Check for CIs (below)

Tenecteplase Dosing²

Preferred Anticoagulants³

Factor	Agent
Cancer	LMWH
Parenteral Therapy CI	Rivaroxaban or Apixaban (others require bridge)
QD PO Therapy Preferred	Rivaroxaban, Edoxaban, Warfarin
Liver disease / coagulopathy	LMWH
CrCl < 30	Warfarin
CAD	Warfarin, Rivaroxaban, Apixaban, Edoxaban
Hx of GI Bleeds	Apixaban, Warfarin
Thrombolytic Use	UFH Infusion
Pregnancy	LMWH

Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in Nonorthopedic Surgical Patients. Chest. 2012;141(2):e227S-e277S. doi:10.1378/chest.11-2297 ↩
Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶
Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease. Chest. 2016;149(2):315-352. doi:10.1016/j.chest.2015.11.026 ↩ ↩² ↩³ ↩⁴