Patient handout

Deep vein thrombosis

PRODUCTION

1. Your condition

This handout is for deep vein thrombosis. Your care team identified this based on: unilateral leg swelling / pain / warmth (wells lancet 1997).

Other reasons your team may use this plan: phlegmasia cerulea dolens (limb-threatening); ash 2020; d-dimer elevated in symptomatic patient (age-adjusted cutoff; adjust-dvt/pe, righini jama 2014); compression us showing proximal dvt (ash 2018).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
apixaban	10 mg BID × 7 days → 5 mg BID	PO	BID	AMPLIFY (Agnelli NEJM 2013; PMID 23808982) — no LMWH bridge needed; preferred over warfarin per ASH 2020
rivaroxaban	15 mg BID × 21 days → 20 mg daily with food	PO	BID then daily	EINSTEIN-DVT (Bauersachs NEJM 2010) — no LMWH bridge; CrCl ≥30
edoxaban	60 mg daily (30 mg if CrCl 15–50, ≤60 kg, or P-gp inhibitor)	PO	once daily	Hokusai-VTE (Büller NEJM 2013; PMID 23991658) — requires 5-day LMWH lead-in
dabigatran	150 mg BID after 5–10 d LMWH lead-in	PO	BID	RE-COVER (Schulman NEJM 2009) — needs LMWH lead-in; idarucizumab reversal available
enoxaparin	1 mg/kg SC q12h OR 1.5 mg/kg SC daily (CrCl <30: 1 mg/kg daily)	SC	q12h or daily	CLOT (Lee NEJM 2003) — preferred in active GI/GU mucosal cancer; pregnancy first-line per ASH 2018
dalteparin	200 IU/kg SC daily × 1 mo → 150 IU/kg	SC	daily	CLOT (Lee NEJM 2003) — alternate LMWH for cancer-associated VTE
heparin	80 U/kg bolus + 18 U/kg/h infusion targeting aPTT 1.5–2.5×	IV	continuous	Rapid reversibility; preferred when intervention possible (ACCP 2016 Kearon)
warfarin	Start 5 mg PO with overlapping LMWH × ≥5 d AND until INR ≥2 for ≥24 h	PO	daily; INR-driven	TRAPS (Pengo Blood 2018) — warfarin preferred in triple-positive APS over rivaroxaban
fondaparinux	5 mg <50 kg / 7.5 mg 50–100 kg / 10 mg >100 kg SC daily	SC	daily	Alternative when LMWH/UFH not appropriate; ACCP 2016 recommendation for HIT

Plan: DVT anticoagulation — DOAC-first per ASH 2020 / ACCP 2021

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Doing well — leg improving, no bleed, AC adherent (ASH 2020)

If you have:

Leg swelling and pain improving
No bleeding (no melena, hematuria, severe bruising)
Taking AC as prescribed (ACCP 2016)

Do this:

Continue AC every day (ASH 2020)
Keep follow-up appointments
Stay active (walking) but avoid contact sports (ASH 2020)
Do not skip a dose; if missed, take when remembered (apixaban: skip if >6 h late per FDA label 2023)

YELLOW — Caution — minor bleed, missed dose, leg worse (ASH 2020)

If you have:

Easy bruising or minor nosebleed lasting >10 min (ISTH bleeding definition 2005)
Missed AC dose >1
New leg pain or swelling without limb-threatening features
Black stools without dizziness (ACCP 2016)

Do this:

Resume AC at next dose (ASH 2020)
Apply pressure to bleeding
Schedule provider visit within 24–48 h
Ultrasound may be repeated by provider (ASH 2018)

Call your provider if:

Bleeding does not stop in 15 min with pressure
Multiple missed doses (ACCP 2016)
Worsening leg symptoms

RED — Medical alert — major bleed, PE, or limb-threatening DVT (ASH 2020)

If you have:

Vomiting blood, melena, severe nosebleed, intracranial symptoms (severe headache, vision change, weakness, confusion) per ISTH major bleeding criteria 2005
Sudden chest pain, dyspnea, syncope, hemoptysis (PE concern; ESC 2019)
Severe leg pain + cold/pale/blue limb (phlegmasia; ASH 2020)
Major trauma or fall with head injury on AC (ACCP 2016)

Do this:

Call 911 / go to ED immediately
Bring AC name + last dose time
Apply pressure to external bleeding
Do NOT take additional AC doses (ASH 2020)

Call your provider if:

Any red zone symptom — ED is destination (ASH 2020)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Limb-threatening DVT — pale or blue, cold, severely painful limb with severe iliofemoral DVT (ASH 2020)(life-threatening)
DVT + PE features (dyspnea, hypoxemia, RV strain on echo, syncope) per ESC 2019
Major bleeding on DOAC or warfarin (Hgb drop >2, transfusion, ICH, GI requiring hospitalization) per ISTH criteria 2005(life-threatening)
Pregnant patient with new or known DVT (ASH 2018)

5. Follow-up

3-month vs extended AC review at 3 mo for unprovoked (ACCP 2016); DASH (Tosetto JTH 2012)/HERDOO2 (Rodger BMJ 2017) risk-of-recurrence; aspirin after stopping AC (ASPIRE Brighton NEJM 2012); PTS rehabilitation

6. Sources

Guideline: ASH 2018/2020/2023 VTE Guidelines + ACCP/CHEST 2021/2024 Antithrombotic + NICE NG158 + ISTH 2022 cancer-VTE