Skip to main content
SpringerLink
Log in

Treatment of Venous Thromboembolism

  • Chapter
Anticoagulation Management

  • 970 Accesses

Abstract

The treatment of venous thromboembolism (VTE), which consists of pulmonary embolism (PE) or deep vein thrombosis (DVT), can be complex. In recent years the introduction of novel pharmacologic treatments, as well as, increased use of catheter-directed thrombolysis, systemic intravenous thrombolysis, and surgical embolectomy interventions have been utilized either instead of or in addition to traditional VTE treatment with the hopes to improve outcomes. Traditional treatment options for VTE continue to be unfractionated heparin (UFH), low molecular weight heparin (LMWH), and oral vitamin K antagonists (warfarin).

As with any anticoagulant, there are challenges in selecting the most appropriate therapy based on individual patient factors, determining length of anticoagulation therapy, providing education, and monitoring outcomes. This chapter will focus on how the pharmacist can impact each of these challenges when treating VTE in either the inpatient or ambulatory settings.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 39.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 54.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 54.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Kearon C, Akl EA, Comerota AJ et al (2012) Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed. American college of chest physicians evidence based clinical practice guidelines. Chest 141:e419s–e494s

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  2. Dupras D, Bluhm J, Felty C, et al (2013) Institute for clinical systems improvement: venous thromboembolism diagnosis and treatment. Available via http://bit.ly/VTE0113. Accessed 10 Mar 2015

  3. Agnelli G, Buller HR, Cohen A et al (2013) Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med 369(9):799–808

    Article  CAS  PubMed  Google Scholar 

  4. Agnelli G, Buller HR, Cohen A et al (2013) Apixaban for extended treatment of venous thromboembolism. N Engl J Med 368(8):699–708

    Article  CAS  PubMed  Google Scholar 

  5. Schulman S, Kearon C, Kakkar AK et al (2013) Extended use of dabigatran, warfarin or placebo in venous thromboembolism. N Engl J Med 368:709–718

    Article  CAS  PubMed  Google Scholar 

  6. Schulman S, Kearon C, Kakkar AK et al (2009) Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med 361:2342–2352

    Article  CAS  PubMed  Google Scholar 

  7. The Hokusai-VTE Investigators (2013) Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med 369:1406–1415

    Article  Google Scholar 

  8. Buller HR, Prins MH, Lensing AW et al (2012) Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med 366:1287–1297

    Article  PubMed  Google Scholar 

  9. Bauersachs R, Berkowitz SD, Brenner B et al (2010) Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 363:2499–2510

    Article  CAS  PubMed  Google Scholar 

  10. Spyropoulos AC, Lin J (2007) Direct medical cost of venous thromboembolism and subsequent hospital readmission rates: an administrative claims analysis from 30 managed care organizations. J Manag Care Pharm 13(6):475–486

    PubMed  Google Scholar 

  11. Mahan CE, Borrego ME, Woersching AL et al (2012) Venous thromboembolism: annualized United States models for total, hospital acquired and preventable costs utilizing long-term attack rates. Thromb Haemost 108:291–302

    Article  CAS  PubMed  Google Scholar 

  12. Grau E, Tenias JM, Real E et al (2001) Home treatment of deep vein thrombosis with low molecular weight heparin: long term incidence of recurrent venous thromboembolism. Am J Hematol 67:10–14

    Article  CAS  PubMed  Google Scholar 

  13. Ramacciotti E, Araujo GR, Lastoria S et al (2004) An open-label, comparative study of the efficacy and safety of once-daily dose of enoxaparin versus unfractionated heparin in the treatment of proximal lower limb deep-vein thrombosis. Thromb Res 114:149–153

    Article  CAS  PubMed  Google Scholar 

  14. Koopman MM, Prandoni P, Piovella F et al (1996) Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular weight heparin administered at home. The Tasman Study Group. N Engl J Med 334:682–687

    Article  CAS  PubMed  Google Scholar 

  15. Piran S, Le Gal G, Wells PS et al (2013) Outpatient treatment of symptomatic pulmonary embolism: a systematic review and meta-analysis. Thromb Res 132:515–519

    Article  CAS  PubMed  Google Scholar 

  16. Erkens P, Gandara E, Wells PS et al (2012) Does the pulmonary embolism severity index accurately identify low risk patients eligible for outpatient treatment. Thromb Res 129:710–714

    Article  CAS  PubMed  Google Scholar 

  17. Aujesky D, Roy P, Verschuren F et al (2011) Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomized, non-inferiority trial. Lancet 378:41–48

    Article  PubMed  Google Scholar 

  18. Provias T, Dudzinski DM, Jaff MR et al (2014) The Massachusetts general hospital pulmonary embolism response team (MGH PERT): creation of a multidisciplinary program to improve care of patients with massive and submassive pulmonary embolism. Hosp Pract 42(1):31–37. doi:10.3810/hp.2014.02.1089

    Article  Google Scholar 

  19. Kabrhel C, Jaff MR, Channick RN et al (2013) A multidisciplinary pulmonary embolism response team. Chest 144:1738–1739

    Article  PubMed  Google Scholar 

  20. Marano P, Cina G, Cotroneo AR et al (1996) Multidisciplinary approach to venous thromboembolism. Rays 21(3):481–499

    CAS  PubMed  Google Scholar 

  21. Bates SM, Jaeschke R, Stevens SM et al (2012) Diagnosis of DVT: antithrombotic therapy and prevention of thrombosis, 9th ed. American college of chest physicians evidence based clinical practice guidelines. Chest 141:e351s–e481s

    PubMed Central  CAS  PubMed  Google Scholar 

  22. Wells PS, Anderson DR, Rodger M et al (2000) Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increase the models utility with the SimpliRED D-dimer. Thromb Haemost 83(3):416–420

    CAS  PubMed  Google Scholar 

  23. Wells PS, Anderson DR, Rodger M et al (2001) Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med 135(2):98–107

    Article  CAS  PubMed  Google Scholar 

  24. Wolf SJ, McCubbin TR, Feldhaus KM et al (2004) Prospective validation of Wells criteria in the evaluation of patients with suspected pulmonary embolism. Ann Emerg Med 44(5):503–510

    Article  PubMed  Google Scholar 

  25. Stein PD, Woodard PK, Weg JD et al (2007) Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. Radiology 242(1):15–21. doi:10.1148/radiol.2421060971

    Article  PubMed  Google Scholar 

  26. Van Belle A, Buller HR, Huisman MV et al (2006) Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA 295(2):172–179. doi:10.1001/jama.295.2.172

    Article  PubMed  Google Scholar 

  27. Wells PS, Anderson DR, Bormanis J et al (1997) Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet 350(9094):1795–1798

    Article  CAS  PubMed  Google Scholar 

  28. Kearon C, Julian JA, Newman TE et al (1998) Non-invasive diagnosis of deep vein thrombosis. Ann Intern Med 128:663–677

    Article  CAS  PubMed  Google Scholar 

  29. Carpenter JP, Holland GA, Baum RA et al (1993) Magnetic resonance venography for the detection of deep vein thrombosis: comparison with contrast venography and duplex Doppler ultrasonography. J Vasc Surg 18:734–741

    Article  CAS  PubMed  Google Scholar 

  30. Peterson DA, Kazerooni EA, Wakefield TW et al (2001) Computed tomography venography is specific but not sensitive for diagnosis of acute lower extremity deep vein thrombosis in patients with suspected pulmonary embolism. J Vasc Surg 34:798–804

    Article  CAS  PubMed  Google Scholar 

  31. Jongbloets LMM, Lensing AWA, Koopman MMW, Buller HR, ten Cate JW (1994) Limitations of real-time compression ultra-sound for the detection of asymptomatic deep-vein thrombosis in postoperative patients. Lancet 343:1142–1144

    Article  CAS  PubMed  Google Scholar 

  32. Heijboer H, Buller HR, Lensing A, Turpie A, Colly LP, ten Cate JW (1993) A comparison of real-time compression ultra-sonography with impedance plethysmography for the diagnosis of deep-vein thrombosis in symptomatic outpatients. N Engl J Med 329:1365–1369

    Article  CAS  PubMed  Google Scholar 

  33. Stein PD, Fowler SE, Goodman LR et al (2006) Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 354(22):2317–2327. doi:10.1056/NEJMoa052367

    Article  CAS  PubMed  Google Scholar 

  34. Sostman HD, Stein PD, Gottschalk A et al (2008) Acute pulmonary embolism: sensitivity and specificity of ventilation-perfusion scintigraphy in PIOPED II study. Radiology 246(3):941–946

    Article  PubMed  Google Scholar 

  35. Miniati M, Monti S, Pratali L et al (2001) Value of transthoracic echocardiography in the diagnosis of pulmonary embolism: results of a prospective study in unselected patients. Am J Med 110(7):528–535

    Article  CAS  PubMed  Google Scholar 

  36. Stein PD, Chenevert TL, Fowler SE et al (2010) Gadolinium-enhanced magnetic resonance angiography for pulmonary embolism: a multicenter prospective study (PIOPED III). Ann Intern Med 152(7):434–443

    Article  PubMed Central  PubMed  Google Scholar 

  37. Product Information: heparin sodium injection (2014) Pfizer, Kirkland

    Google Scholar 

  38. Smith SB, Geske JB, Maguire JM et al (2010) Early anticoagulation is associated with reduced mortality for acute pulmonary embolism. Chest 137(6):1382–1390

    Article  PubMed Central  PubMed  Google Scholar 

  39. Hatjipetrou A, Anyfantakis D, Kastanakis M (2015) Rectus sheath hematoma: a review of the literature. Int J Surg 13:267–271

    Article  PubMed  Google Scholar 

  40. Enoxaparin [package insert] (2013) Sanofi-Aventis US LLC, Bridgewater

    Google Scholar 

  41. Dalteparin [package insert] (2014) Pfizer, Kirkland

    Google Scholar 

  42. Tinzaparin [package insert] (2010) LEO Pharmaceuticals Company, Parsipany

    Google Scholar 

  43. Nadroparin [package insert] (2011) GlaxoSmithKline Inc, Mississauga

    Google Scholar 

  44. Ageno W, Gallus AS, Wittkowsky A et al (2012) Oral anticoagulant therapy, antithrombotic therapy and prevention of thrombosis, 9th ed. American college of chest physicians evidence based clinical practice guidelines. Chest 141:e44s–e88s

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  45. Pawloski SJ, Kersh PL (1992) Therapeutic heparin monitoring service in a small community hospital. Hosp Pharm 27(8):703–706

    CAS  PubMed  Google Scholar 

  46. Saya FG, Coleman LT, Martinoff JT (1985) Pharmacist-directed heparin therapy using a standard dosing and monitoring protocol. Am J Hosp Pharm 42(9):1965–1969

    CAS  PubMed  Google Scholar 

  47. Bond CA, Raehl CL (2004) Pharmacist provided anticoagulation management in United States hospitals: death rates, length of stay, medicare charges, bleeding complications and transfusions. Pharmacotherapy 24:953–963

    Article  CAS  PubMed  Google Scholar 

  48. Price C, Colodny L (2000) Partnering with nurses to manage heparin therapy with a weight based protocol. Am J Health Syst Pharm 57(2):110–112, 115–116

    CAS  PubMed  Google Scholar 

  49. Dobesh PP, Trujillo TC, Finks SW (2013) Role of the pharmacist in achieving performance measures to improve the prevention and treatment of venous thromboembolism. Pharmacotherapy 33(6):650–664

    Article  PubMed  Google Scholar 

  50. Dawson NL, Porter IE, Klipa D et al (2012) Inpatient warfarin management: pharmacist management using a detailed dosing protocol. J Thromb Thrombolysis 33:178–184

    Article  CAS  PubMed  Google Scholar 

  51. Fowler S, Gulseth MP, Renier C et al (2012) Inpatient warfarin: experience with a pharmacist-led anticoagulation management service in a tertiary care medical center. Am J Health Syst Pharm 69:44–48

    Article  PubMed  Google Scholar 

  52. Strieff MB (2015) Predicting the risk of recurrent venous thromboembolism (VTE). J Thromb Thrombolysis 39:353–366

    Article  Google Scholar 

  53. Iorio A, Kearon C, Filippucci E et al (2010) Risk of recurrence after a first episode of symptomatic venous thromboembolism provoked by a transient risk factor: a systematic review. Arch Intern Med 170:1710–1716

    PubMed  Google Scholar 

  54. Douketis J, Tosetto A, Marcucci M et al (2011) Risk of recurrence after venous thromboembolism in men and women: patient level meta-analysis. BMJ 342:d813

    Article  PubMed Central  PubMed  Google Scholar 

  55. McRae S, Tran H, Schulman S et al (2006) Effect on patient’s sex on risk of recurrent venous thromboembolism: a meta-analysis. Lancet 368:371–378

    Article  PubMed  Google Scholar 

  56. Bates SM, Greer IA, Middeldorp S et al (2012) VTE, thrombophilia, antithrombotic therapy, and pregnancy: antithrombotic therapy and prevention of thrombosis, 9th ed. American college of chest physicians evidence based clinical practice guidelines. Chest 141:e691s–e736s

    PubMed Central  CAS  PubMed  Google Scholar 

  57. Prandoni P, Lensing AW, Picciolo A et al (2002) Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis. Blood 100:3484–3488

    Article  CAS  PubMed  Google Scholar 

  58. Le Gal G, Righini M, Roy PM et al (2006) Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med 144:165–171

    Article  PubMed  Google Scholar 

  59. Klok FA, Mos I, Nijkeuter M et al (2008) Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med 168(19):2131–2136

    Article  PubMed  Google Scholar 

  60. Rodger MA, Kahn SR, Wells PS et al (2008) Identifying unprovoked thromboembolism patients at low risk for recurrence who can discontinue anticoagulant therapy. CMAJ 179:417–426

    Article  PubMed Central  PubMed  Google Scholar 

  61. Tosetto A, Iorio A, Marcucci M et al (2012) Predicting disease recurrence in patients with previous unprovoked venous thromboembolism: a proposed prediction score (DASH). J Thromb Haemost 10:1019–1025. See comment in PubMed Commons below

    Article  CAS  PubMed  Google Scholar 

  62. Louzada ML, Carrier M, Lazo-Langner A et al (2012) Development of a clinical prediction rule for risk stratification of recurrent venous thromboembolism in patients with cancer-associated venous thromboembolism. Circulation 126:448–454

    Article  PubMed  Google Scholar 

  63. Den Exter PL, Kooiman J, Huisman MV (2013) Validation of the Ottawa prognostic score for the prediction of recurrent venous thromboembolism in patients with cancer-associated thrombosis. J Thromb Haemost 11:998–1000

    Article  Google Scholar 

  64. Leger S, Allenet B, Pichot O et al (2004) Impact of an education program on patient behavior favoring prevention of drug-related adverse events: a pilot study in patients receiving oral anticoagulants for thromboembolic venous disease. J Mal Vasc 29(3):152–158

    Article  CAS  PubMed  Google Scholar 

  65. Moreland CJ, Kravitz RL, Paterniti DA et al (2013) Anticoagulation education: do patients understand potential medication-related emergencies? Jt Comm J Qual Patient Saf 39(1):22–31

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Anticoagulation Stewardship Program, University of Wisconsin Hospital and Clinics, 600 Highland Ave., Madison, WI, 53792, USA

    Anne E. Rose PharmD

Authors
  1. Anne E. Rose PharmD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Anne E. Rose PharmD .

Editor information

Editors and Affiliations

  1. Madison, Wisconsin, USA

    Anne Rose

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Rose, A.E. (2015). Treatment of Venous Thromboembolism. In: Rose, A. (eds) Anticoagulation Management. Adis, Cham. https://doi.org/10.1007/978-3-319-22602-6_7

Download citation

Publish with us

Policies and ethics

Search

Navigation