• Michigan Quality Improvement Consortium. Outpatient management of uncomplicated deep venous thrombosis. Southfield (MI): Michigan Quality Improvement Consortium; 2007 Aug. 1 p.

This is the current release of the guideline.

This guideline updates a previous version: Michigan Quality Improvement Consortium. Outpatient management of uncomplicated deep vein thrombosis. Southfield (MI): Michigan Quality Improvement Consortium; 2005 Aug. 1 p.

The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.

Initial Assessment

• Perform initial comprehensive history and physical examination; consider conditions predisposing to deep vein thrombosis (DVT).
• Assess risk factors and contraindications to outpatient anticoagulation therapy. (See "Contraindications" field in this summary.)
• Assess patient/caregiver ability and compliance for outpatient therapy and need for homecare resources

Pharmacologic Interventions

• Outpatient therapy is preferred if no contraindications (see "Contraindications" field in this summary)
• Begin warfarin after 1^st dose of low molecular weight heparin (LMWH) [A]; on same day, titrate to International normalized ratio (INR) range of 2.0 to 3.0.
• Continue LMWH until INR range 2.0 to 3.0 for 2 consecutive days (usually LMWH 5 to 7 days) [A].
• Maintain warfarin therapy at least 3 months in therapeutic INR range [A], longer if risk of recurrence.
• Ask about any changes in diet, medications, and compliance before any dosage adjustment.

Testing/Monitoring

• Obtain baseline lab values: activated partial thromboplastin time (aPTT), prothrombin time (PT)/INR, complete blood count (CBC) with platelet count. Consider platelet count 3 to 5 days into anticoagulation therapy.
• Monitor warfarin therapy using INR; no lab monitoring required for LMWH unless special circumstances such as renal insufficiency or extremes of body weight.
• Frequent INR monitoring is necessary at the onset of therapy (e.g., at least 2 checks in the first week of therapy); then at least 2 to 3 times per week for the next 1 to 2 weeks. When stable, monitor every 4 to 8 weeks.
• Maintain an Anticoagulant Monitoring Log (or dose adjustment system) for each patient treated with warfarin.
• Monitor common bleeding sites: gums, nose, gastrointestinal, genitourinary, and skin.
• Monitor for signs/symptoms of pulmonary embolism, risk factors, and side effects.
• Management through a specialized program for anticoagulation monitoring, if available.

Patient Education

• Inform patient/caregiver of the reasons for and benefits of therapy, potential side effects, importance of follow-up monitoring, warfarin dosage adjustment, compliance, dietary recommendations (i.e., a diet that is constant in vitamin K), the potential for drug interactions, safety precautions, and recognizing internal bleeding.
• Instruct patient/caregiver on symptoms of pulmonary embolism, extension of DVT, and self-injection of LMWH.
• The patient should be encouraged to be ambulatory after an appropriate weight-based dose of LMWH [D].
• Compression stocking should be used routinely to prevent postthrombotic syndrome [A], beginning within 1 month of diagnosis of proximal DVT and continuing for a minimum of 1 year.

Definitions:

Levels of Evidence for the Most Significant Recommendations

1. Randomized controlled trials
2. Controlled trials, no randomization
3. Observational studies
4. Opinion of expert panel

None provided

The type of evidence is provided for the most significant recommendations (See "Major Recommendations" field).

This guideline is based on several sources, including: Management of Venous Thromboembolism: A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2007;146:204-10.

• Michigan Quality Improvement Consortium. Outpatient management of uncomplicated deep venous thrombosis. Southfield (MI): Michigan Quality Improvement Consortium; 2007 Aug. 1 p.

This guideline is based on several sources, including: Management of Venous Thromboembolism: A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2007;146:204-10.

2003 Aug (revised 2007 Aug)

Michigan Quality Improvement Consortium - Professional Association

Michigan Quality Improvement Consortium

Michigan Quality Improvement Consortium Medical Director's Committee

Physician representatives from participating Michigan Quality Improvement Consortium health plans, Michigan State Medical Society, Michigan Osteopathic Association, Michigan Association of Health Plans, Michigan Department of Community Health and Michigan Peer Review Organization

Standard disclosure is requested from all individuals participating in the Michigan Quality Improvement Consortium (MQIC) guideline development process, including those parties who are solicited for guideline feedback (e.g. health plans, medical specialty societies). Additionally, members of the MQIC Medical Directors' Committee are asked to disclose all commercial relationships.

This is the current release of the guideline.

This guideline updates a previous version: Michigan Quality Improvement Consortium. Outpatient management of uncomplicated deep vein thrombosis. Southfield (MI): Michigan Quality Improvement Consortium; 2005 Aug. 1 p.

None available

None available

This NGC summary was completed by ECRI on April 14, 2004. The information was verified by the guideline developer on July 27, 2004. This NGC summary was updated by ECRI on November 28, 2005. The updated information was verified by the guideline developer on December 19, 2005. This summary was updated by ECRI on March 6, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin sodium). This summary was updated by ECRI Institute on June 22, 2007 following the U.S. Food and Drug Administration (FDA) advisory on heparin sodium injection. This summary was updated by ECRI Institute on September 7, 2007 following the revised U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin). This NGC summary was updated by ECRI Institute on March 5, 2008. The updated information was verified by the guideline developer on March 12, 2008.

This NGC summary is based on the original guideline, which may be reproduced with the citation developed by the Michigan Quality Improvement Consortium.