DEEP VEIN THROMBOSIS (DVT) April 2018 Page 1 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

Deep Vein Thrombosis (DVT) Medicine > General medicine > Deep Vein Thrombosis (DVT)

POAC Provider

Resources

Pasifika Hauora Māori Updates to this care

map

Information resources

for clinicians

Information resources

for patients and carers

RED FLAGS History & Clinical

Examination

Refer to the Medical

Registrar, MCH

Calculate Wells

Clinical Score

High Probability (2) Low Probability (<2)

Arrange USS, and

Blood test without

D-dimer

Urgent D-dimer and

other blood tests

Positive D-dimer

(500)

Negative D-dimer

(<500)

Arrange ultrasound

scan

Scan/Result expected

today

Scan/Result not

available today

Ultrasound report

available

Positive Ultrasound Negative Ultrasound

Commence oral

anticoagulant therapy

Ongoing symptoms -

Review within 7 days

Rivaroxaban Precautions Warfarin Risk factors Dabigatran Precautions

Review by specialist

team GPT AND

Haematology titration

Warfarin - General

Practice Team titration

Review by specialist

team

Review by specialist

team

Review by specialist

team

Care map

information

Patient unsuitable for

anticoagulation

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 2 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

1. Care Map Information

In Scope:

• the diagnosis and management of deep vein thrombosis (DVT) presenting in adults

2. Information resources for patients and carers

• Confirmed DVT Patient Information - I have a clot

• Herbal Medicines & Warfarin

• Warfarin patient information brochure

• Dabigatran patient information

• Rivaroxaban (Xarelto) patient Information

• Day 4 INR Instructions

• Patient administration guide - Enoxaparin (Clexane)

• Te Ara Whānau Ora Brochure

3. Information resources for clinicians

• Suspected DVT Provider Checklist

• Confirmed DVT Provider Discharge Checklist

• Wells Score Sheet

• Ultrasound Request Form

• Cockcroft-Gault formula

• Enoxaparin (Clexane) Administration Form for patients on the DVT Pathway

• Enoxaparin (Clexane) Dosage Calculation Table

• Enoxaparin (Clexane) information - NZ Formulary

• Patient Warfarin learning checklist

• Warfarin counselling checklist

• Warfarin dosing table

• Dabigatran information – NZ Formulary

• Rivaroxaban information – NZ Formulary

• 6 week follow-up and/or warfarin monitoring - Haematology Service Referral Form

• POAC Transfer of Care/Handover form

• The safe and effective use of dabigatran and warfarin in primary care (BPAC, June 2017)

4. Updates to this care map

Date of re-publication: June 2018:

This care map has been updated in line with consideration to evidenced based guidelines. Below summarises changes made to the

pathway following review:

• introducing Rivaroxaban

Date of re-publication: August 2017.

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 3 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

This care map has been updated in line with consideration to evidenced based guidelines. Below summarises changes made to the

pathway following review:

• initiating Warfarin and Dabigatran

Date of re-publication: July 2015.

For further information on contributors and references please see the care map's Provenance.

NB: This information appears on each page of this care map.

5. Hauora Māori

Māori are a diverse people and whilst there is no single Māori identity, it is vital practitioners offer culturally appropriate care when

working with Māori Whānau. It is important for practitioners to have a baseline understanding of the issues surrounding Māori health.

This knowledge can be actualised by (not in any order of priority):

• acknowledging Te Whare Tapa Wha (Māori model of health) when working with Māori Whānau

• asking Māori clients if they would like their Whānau or significant others to be involved in assessment and treatment

• asking Māori clients about any particular cultural beliefs they or their Whānau have that might impact on

assessment and treatment of the particular health issue (Cultural issues)

• consider the importance of whānaungatanga (making meaningful connections) with their Māori client / Whānau

• knowledge of Whānau Ora, Te Ara Whānau Ora and referring to Whānau Ora Navigators where appropriate

• having a historical overview of legislation that has impacted on Māori well-being

For further information:

• Hauora Māori

• Central PHO Māori Health website

6. Pasifika

Pacific Cultural Guidelines (Central PHO) 6MB file

Our Pasifika community:

• is a diverse and dynamic population:

• more than 22 nations represented in New Zealand

• each with their own unique culture, language, history, and health status

• share many similarities which we have shared with you here in order to help you work with Pasifika patients more effectively

The main Pacific nations in New Zealand are:

• Samoa, Cook Islands, Fiji, Tonga, Niue, Tokelau and Tuvalu

Acknowledging The FonoFale Model (pasifika model of health) when working with Pasifika peoples and families.

Acknowledging general pacific guidelines when working with Pasifika peoples and families:

• Cultural protocols and greetings

• Building relationships with your pasifika patients

• Involving family support, involving religion, during assessments and in the hospital

• Home visits

• Contact information

Pasifika Health Service:

The Pasifika Health Service is a service provided free of charge for:

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 4 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

• all Pasifika people living in Manawatu, Horowhenua, Tararua and Otaki who have long term conditions

• all Pasifika mothers and children aged 0-5 years

• an appointment can be made by the patient, doctor or nurse

• the Pasifika Health Service contact details are:

• Palmerston North Office - 06 354 9107

• Horowhenua Office - 06 367 6433 • information brochure

Additional resources:

• Ala Mo'ui - Pathways to Pacific Health and Wellbeing 2014-2018

• Primary care for pacific people: a pacific health systems approach

• Tupu Ola Moui: The Pacific Health Chart Book 2004

• Pacific Health resources

• List of local Māori/Pacific Health Providers

• Central PHO Pacific Health website

7. POAC Provider Resources

POAC Provider Checklist - DVT:

• DVT Poster

• Suspected DVT Provider Checklist

• Confirmed DVT Provider Discharge Checklist

• Wells Score Sheet

• Ultrasound Request Form

• Cockcroft-Gault formula

• Enoxaparin (Clexane) Administration Form for patients on the DVT Pathway

• Enoxaparin (Clexane) Dosage Calculation Table

• Enoxaparin (Clexane) information - NZ Formulary

• Patient Warfarin learning checklist

• Warfarin counselling checklist

• Warfarin dosing table

• Dabigatran information - NZ Formulary

• Rivaroxaban information – NZ Formulary

• 6 week follow-up and/or warfarin monitoring - Haematology Service Referral Form

• POAC Transfer of Care/Handover form

• POAC Referral Centres - Contact List (contains phone and fax numbers)

Patient resources:

• Confirmed DVT Patient Information - I have a clot

• Herbal Medicines & Warfarin

• Warfarin patient information brochure

• Dabigatran patient information

• Rivaroxaban (Xarelto) patient Information

• Day 4 INR Instructions

• Patient administration guide - Enoxaparin (Clexane)

• Te Ara Whānau Ora Brochure

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 5 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

POAC Eligibility Criteria:

• primary provider MUST be registered with POAC to claim POAC services - for more information please contact

027 247 8106

• POAC eligibility criteria

8. RED FLAGS

Refer immediately if:

• suspected deep vein thrombosis (DVT) in pregnancy

• suspected Pulmonary Embolism (PE)

• heparin allergy

• heparin induced thrombocytopenia

• contraindications to anti-coagulation therapy include:

• haemophilia or any other known bleeding disorders

• active bleeding

• platelets <75 [1,5]

Associated other comorbidities:

• clotting disorder

9. History & Clinical Examination

Perform a thorough examination of the legs (including measurement of calf girth, oedema etc). Deep vein thrombosis (DVT) most

likely if calf swollen >3cm compared to asymptomatic leg measured 10cm below tibial tuberosity.

Record onset, location, and character of patient's leg pain and swelling [1, 2].

The Homans sign has no clinical value in assessing expected DVT [1].

Risk factors include:

• increasing age

• obesity

• varicose veins

• family history

• Thrombophilia

• other thrombotic states e.g:

• cancer

• heart failure

• recent MI

• stroke etc

• combined oral contraceptive

• oral oestrogen HRT

• Raloxifene/ Tamoxifen

• pregnancy/ puerperium

• immobility/ travel immobility

• hospitalisation

• anaesthesia

• central venous catheters [7]

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 6 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

10. Calculate Wells Clinical Score

Fill in Wells Score sheet to calculate score [1,2,6,7].

Score Sheet

Alternative diagnoses:

• cellulitis - See cellulitis pathway

• bakers cyst

• muscle or soft tissue injury

• lymphangitis

• superficial thrombophlebitis

• obstruction of lymph drainage

• compression of a major vein

• arthritis [1,2,5]

14. Arrange USS and Blood test without D-dimer

DO NOT START WARFARIN UNTIL DVT CONFIRMED.

For diagnosis; arrange ultrasound scan (USS).

Procedure for arranging ultrasound scan:

• print off and complete Ultrasound Request Form

• arrange urgent USS by contacting a suitable radiology provider as per the Community Radiology Contract

• ensure patient takes a copy of the ultrasound request form to the radiology provider [1,2]

To assess suitability for anticoagulation therapy arrange the following bloods:

• FBC

• LFTs

• Creatinine

• Coag study [1, 7]

If coagulation results are abnormal or thrombocytopenia is present discuss management with a haematologist.

15. Urgent D-dimer and other blood tests

Collect blood and send to Medlab Central, PN Hospital - ph (06) 952 3180.

Mark as 'Urgent D-Dimer/ DVT Pathway' - provide after hours contact phone number to receive result:

• D-dimer

• FBC

• LFTs

• Creatinine

• Coag study [1,6]

If coagulation results are abnormal or thrombocytopenia is present discuss management with a haematologist.

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 7 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

16. Positive D-dimer (>500)

Arrange ultrasound scan

A positive D-dimer result means a deep vein thrombosis (DVT) could be present, but a positive result does not confirm the diagnosis

of a DVT. The D-dimer should not be used as a diagnostic test as the Positive Predictive Value is only around 30%.

Other causes of a raised D-dimer include:

• infection

• inflammation

• trauma

• post surgery

• haemorrhage [3,4]

17. Negative D-dimer (<500)

A negative result with a low probability Wells score virtually excludes a deep vein thrombosis (DVT).

In several series, the Negative Predictive Value is between 98-100%. Therefore <2% of patients with a negative result will have a

DVT or PE [3,4,].

Patients should be informed that a diagnosis of DVT may still become apparent during 3 months of follow-up [7].

18. Arrange ultrasound scan

Procedure for arranging ultrasound scan (USS):

• print off and complete Ultrasound Request Form

• arrange urgent USS by contacting a suitable radiology provider as per the Community Radiology Contract

• ensure patient takes a copy of the ultrasound request form to the radiology provider [1,2]

DO NOT START WARFARIN UNTIL DVT CONFIRMED

19. Scan/Result expected today

No Enoxaparin (Clexane) to be administered until scan result confirms deep vein thrombosis (DVT) later the same day [1,2].

DO NOT START ORAL ANTICOAGULATION UNTIL DVT CONFIRMED.

20. Scan/Result not available today

IF ULTRASOUND NOT AVAILABLE SAME DAY.

Check blood test results (taken earlier today).

Check suitability for Enoxaparin (Clexane) (NZF) and ensure no contraindications to Enoxaparin (Clexane):

• START ENOXAPARIN (Clexane) (if appropriate) now and continue until scan result known

• ensure there is a plan in place for the patient to receive an adequate supply of Enoxaparin (Clexane) until scan result is known

Prior to commencing Enoxaparin (Clexane), it is recommended that all patients:

• are weighed - utilise Enoxaparin (Clexane) Dosage Calculation Table

• have their recent creatinine clearance calculated using the Cockcroft-Gault formula. The eGFR calculated by the laboratory can

be used as an indicator of renal impairment but the creatinine clearance equation should be used to guide dosage adjustment

• complete the Enoxaparin (Clexane) Request Form if your practice does not have clexane in stock

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 8 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

• receive Patient administration guide - Enoxaparin (Clexane)

Patients without renal impairment (CrCl >30mls/min):

• prophylaxis of venous thromboembolism: 40mg daily

• treatment of venous thromboembolism: 1.5mg/kg once daily or 1mg/kg twice daily

Patients with renal impairment (CrCl <30mls/min):

• prophylaxis of venous thromboembolism: 20mg daily

• treatment of venous thromboembolism:

• an initial standard dose of Enoxaparin (Clexane) based on the patient's actual body weight is used so that an effective

concentration is achieved rapidly:

• if a patient weighs more than 100Kg we recommend clexane 1mg/kg bd up to a max of 150mg bd

• for a patient over 150kg we recommend 150mg bd

• however, for patients with reduced renal function (i.e. creatinine clearance less than 30mL/min), subsequent doses require

adjustment because of the risk of over-coagulation and bleeding

• for patients with creatinine clearance less than 30mL/min, Enoxaparin (Clexane) should be dosed at 1mg/kg once daily

• consultation with Haematology is recommended for this group

DO NOT START WARFARIN, DIBIGATRAN OR RIVAROXABAN UNTIL DVT CONFIRMED [1,2].

Contraindications to anti-coagulation therapy include:

• haemophilia or any other known bleeding disorders

• heparin induced thrombocytopenia

• active bleeding

• platelets <75

• allergy to heparin [1,2]

IF CONTRAINDICATIONS TO ENOXAPARIN (CLEXANE), URGENT REFERAL TO MEDICAL REGISTRAR ON-CALL.

22. Patient unsuitable for anticoagulation

Consult with on-call Haematologist in the first instance; if unavailable, refer to the on-call Medical Registrar, MidCentral Health.

If the patient has any of the following refer to acute medicine (Medical Registrar on call):

• abnormal liver function

• thrombocytopenia (Plts <75)

• abnormal coagulation

• active bleeding

• dementia

• confusion

• high falls risk

• alcoholism

• risky lifestyle

• known bleeding disorder

• prior history of heparin induced thrombocytopenia

• heparin allergy [1]

23. Positive Ultrasound

Deep vein thrombosis (DVT) is confirmed and the radiology provider will:

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 9 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

• phone and advise GP of result [1]

• fax details to Haematology service on (06) 350 8551 (all patients for the purposes of a six week follow up)

The patient has a confirmed deep vein thrombosis (DVT) and needs anticoagulant therapy.

Assess the patient's suitability for anticoagulation.

24. Negative Ultrasound

Patient requires review by GP/NP.

If superficial thrombophlebitis is confirmed following an ultrasound, consult with the on-call Clinical Haematologist for appropriate

management.

25. Ongoing symptoms – Review within 7 days

Diagnosis of deep vein thrombosis (DVT) is highly unlikely.

Advise patient to re-present if symptoms persist or new symptoms of shortness of breath and chest pain develop.

If symptoms persist, GP to review [1, 7].

26. Commence oral anticoagulant therapy

There are 3 options for treating a DVT: Rivaroxaban (NZF), Dabigatran (NZF) or Warfarin (NZF):

• each medication has advantages and disadvantages. They have different side-effect profiles, therefore it is reasonable to try

an alternative if your patient experiences side-effects with one medication.

• the large multicentre trials suggest that Rivaroxaban and Dabigatran have a lower incidence intracranial bleeding than

Warfarin, so consider one of the newer anticoagulants as first choice. However these drugs should be used with caution in

patients with renal impairment (especially Dabigatran) as they can accumulate and cause bleeding.

• Warfarin and Dabigatran can be reversed rapidly. There is no reversal agent for Rivaroxaban.

• the frail elderly at high risk of falls need special consideration and we recommend specialist consultation for

this group

• consider all medications a patient is currently taking including over the counter herbals etc - to assist patient's to make

an informed choice

Discuss advantages and disadvantages of Rivaroxaban, Warfarin and Dabigatran with patient, allowing the patient to make

an informed choice.

Rivaroxaban – consider as first option.

NB: should not be used in a patient with weight >120kg or with previous gastric bypass surgery.

• advantages:

• can be used from diagnosis (does not require initial treatment with Enoxaparin)

• once daily medication (treatment is given twice daily for 3 weeks for the acute management of DVT and Pulmonary

Embolism (PE), followed by once daily treatment)

• no regular anticoagulant monitoring required

• low incidence of side-effects

• disadvantages:

• no reversal agent available

• cannot be used in moderate-severe renal impairment (CrCl <50ml/min):

• consultation with Haematology is recommended with this group

• menorrhagia reported more frequently than with other anticoagulants

• cannot be used in patients with mechanical heart valves

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 10 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

Dabigatran – consider as first option in patients where rapid reversal of anticoagulation is important, for example in a

patient with a history of a prior bleed. May be a better option in women with a history of menorrhagia.

NB: should not be used in a patient with weight >120kg or with previous gastric bypass surgery.

• advantages:

• no regular anticoagulant monitoring required

• reversal agent available for acute bleeding

• disadvantages:

• requires a 5 days course of Enoxaparin for acute management of DVT and PE, prior to starting Dabigatran

• twice daily medication

• cannot be used in moderate-severe renal impairment (CrCl <50ml/min)

• consultation with Haematology is recommended with this group

• gastro-intestinal side-effects common

• cannot be used in patients with mechanical heart valves

• The safe and effective use of dabigatran and warfarin in primary care (BPAC, June 2017)

Warfarin

• advantages: • allows closer monitoring and adjustment of the level of anticoagulation

• reversal agent available for acute bleeding

• can be used in severe renal failure

• standard therapy for anticoagulant prophylaxis for mechanical heart valves

• can be used to manage antiphospholipid syndrome

• can be used to manage thrombosis at unusual sites

• disadvantages:

• requires at least 5 days of Enoxaparin for acute management of DVT and PE, during Warfarin loading

• requires regular INR monitoring

• multiple drug interactions

• The safe and effective use of dabigatran and warfarin in primary care (BPAC, June 2017)

• Rivaroxaban information - NZ Formulary

• Clexane information - NZ Formulary

• Dabigatran information - NZ Formulary

Ensure that baseline investigations have been completed:

• FBC

• LFTs

• Creatinine

• Coag study [1, 7]

If coagulation results are abnormal or thrombocytopenia is present discuss management with a haematologist.

Haematology Service Referral Form

Useful information for patients:

• Confirmed DVT Patient Information - I have a clot

• use compression stockings (worn for 2 years or beyond if useful)

• ensure patient is adequately hydrated

• early mobilisation and leg exercises [7]

• for patients that elect to self administer clexane, provide the 'helping you to use clexane' brochure produced by Sanofi (to

reorder, freephone 0800 283 684)

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 11 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

27. Rivaroxaban

NB: All strengths (10, 15, 20mg) of Rivaroxaban (NZF) will be funded for use in primary care from 1 August 2018.

Rivaroxaban:

• Rivaroxaban can be used for the acute management of DVT, Enoxaparin treatment is not required.

• exclude patients with moderate-severe renal impairment (i.e. CrCl <50 ml/min) - recommend discussion with Haematology

in this group

• use with caution in patients with abnormal LFTs – Rivaroxaban has been associated with raised transaminases

Starting treatment:

• when DVT confirmed

• commence Rivaroxaban at 15mg oral twice daily for the first 3 weeks, then reduce dose to -

• Rivaroxaban 20mg oral once daily

• Useful information for patients:

• Rivaroxaban (Xarelto) patient Information

28. Precautions

Precautions:

• a recent creatinine and CrCl should be obtained prior to commencing rivaroxaban

• If CrCl <50ml/min, Rivaroxaban should not be used - consult with Haematology

• use with caution in patients with abnormal liver function (recent test required) – raised transaminases have been reported with

rivaroxaban

• assess other risk factors such as falls risk

• NB: there is no reversal agent available for rivaroxaban

A referral to Haematology is required to initiate a follow up appointment in the Thrombosis Clinic for all patients commenced on

Rivaroxaban to determine the duration of therapy.

29. Warfarin

Enoxaparin (Clexane)/Warfarin Pack:

Enoxaparin (Clexane) information - NZ Formulary

The patient has a confirmed deep vein thrombosis (DVT) and needs anticoagulant therapy. Assess the patient's suitability for

anticoagulation.

Considerations:

• if a patient weighs more than 100Kg we recommend clexane 1mg/kg bd up to a max of 150mg bd

• for a patient over 150kg we recommend 150mg bd OR

• discuss with on-call Haematologist

• if the patient has renal impairment (CrCl <30ml/min), commence Enoxaparin (Clexane) 1mg/kg - use the Cockcroft Gault Score

calculator to determine correct dosage

Starting anticoagulant therapy

Advise the patient on how to start treatment. The standardised starter pack contains 8 doses of Enoxaparin (Clexane) (the patient

will be given the correct dose based on their weight) and 100 x 1mg Warfarin tablets.

Timing of oral anticoagulant therapy:

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 12 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

• treatment should be taken at the same time each day

• evening dosing preferred as the INR should be measured 16 hours after a dose of Warfarin (i.e. the following morning)

Useful information for patients:

• Day 4 INR Instructions

• Herbal Medicines & Warfarin

• Warfarin patient information brochure

• Patient administration guide - Enoxaparin (Clexane)

30. Risk factors

Risk factors:

Patients with any of the following risk factors may be particularly sensitive to warfarin or may have an increased risk of bleeding.

In these patients, consider starting treatment with 3mg daily:

• age >65

• albumin <30mg/L

• baseline INR >1.5

• bilirubin >20µmol/L

• PCV <0.3

• platelets <50x109 / L

• creatinine >200µmol/L

• active malignancy

• gastrointestinal bleed

• recent stroke

• uncontrolled CHF

• alcoholism

• major surgery <14 days

• severe hypertension

31. Dabigatran

Dabigatran

Dabigatran information - NZ Formulary - never use Dabigatran and Enoxaparin (Clexane) at the same time - Dabigatran to start

on day 6.

It is important that the person receives 5 doses of therapeutic Enoxaparin (Clexane) 1.5mg/kg (adjust for renal impairment) for

5 days PRIOR to commencing the Dabigatran:

• if a patient weighs more than 100Kg we recommend clexane 1mg/kg bd up to a max of 150mg bd

• for a patient over 150kg we recommend 150mg bd

Exclude patients with moderate-severe renal impairment (i.e. CrCl <50 ml/min):

• consultation with Haematology is recommended with this group

Dabigatran 150mg bd is the recommended dosage for a person with confirmed DVT (110mg bd dose is not appropriate for DVT

treatment).

Patients with adequate renal function (CrCl >50 ml/min) should be treated with a daily dose of 300 mg taken orally as 150 mg

capsules twice daily.

Starting anticoagulant therapy

Advise the patient on how to start treatment. The standardised starter pack contains only 5 doses of Enoxaparin (Clexane) (1.5mg/

kg s/c daily) alongside a script for Dabigatran (as per NZ Formulary ).

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 13 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

• Patient ONLY to commence Dabigatran once Enoxaparin (Clexane) treatment has finished.

• The first dose of Dabigatran should be given 24 hours after the 5th dose of Enoxaparin (Clexane).

If there are any concerns regarding patient therapy consult with Haematology.

Useful information for patients:

• Dabigatran patient information

32. Precautions

Precautions

Use in caution in persons >75 years. A creatinine and CrCl should be obtained prior to commencing the Dabigatran. If CrCl <50ml/

min Dabigatran should not be used.

A referral to Haematology is required to initiate a follow up appointment in the Thrombosis Clinic for all patients commenced on

Dabigatran to determine the duration of therapy.

Assess other risk factors such as falls risk.

33. Review by specialist team

Patients are reviewed by Haematology six weeks post DVT to determine ongoing need and duration of anticoagulation therapy.

34. Review by specialist team

Patients are reviewed by Haematology six weeks post DVT to determine ongoing need and duration of anticoagulation therapy.

35. GPT and Haematology titration

Treatment - General Practice Team (GPT) AND Haematology

1. Check INR before commencing Warfarin; if INR >1.4 discuss with haematologist

2. Commence Enoxaparin (Clexane) 1.5mg/kg s/c daily for at least 5 days and continue until INR > 2 AND commence Warfarin

5mg oral daily (to start as soon as diagnosis is confirmed):

• if the patient is frail or has identified risk factors it is appropriate to start treatment with 3mg daily for the first three days

3. A repeat INR test on day 4 of treatment (ensure patient given form stating for haematology dosing) - patients require

monitoring, education and need to be evaluated during anticoagulation therapy:

• Patient information - Day 4 INR Instructions / Blood Monitoring

4. Fax Haematology Service Referral Form to Haematology (06) 350 8551 to arrange six-week follow up appointment to

discuss duration of anticoagulation therapy

If there are any concerns regarding patient therapy consult with Haematology.

36. Warfarin – General Practice Team titration

Treatment - General Practice Team (GPT) management

Medlab will NOT dose patients whilst on Clexane. If the GPT chooses to undertake this step of the pathway you need to

take responsibility to ensure monitoring of the INR and that the patient is contacted with instructions until such time that

the patient is transferred to Medlab once INR is therapeutic. If unable to manage dosing requirements refer to "GPT AND

Haematology titration" box.

1. Check INR before commencing Warfarin; if INR >1.4 discuss with haematologist

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 14 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

2. Commence Clexane 1.5mg/kg s/c daily (or as determined by renal function - see box 'Warfarin') for at least 5 days and

continue until INR > 2 AND commence Warfarin 5mg oral daily (to start as soon as diagnosis is confirmed - exception if

patient is diagnosed on a Wednesday or Thursday consult Haematology for an alternative plan i.e. commence warfarin on

Friday):

• if the patient is frail or has identified risk factors it is appropriate to start treatment with 3mg daily for the first three days

3. A repeat INR test on day 4 of treatment (ensure patient given form stating for GPT dosing) - patients require

monitoring, education and need to be evaluated during anticoagulation therapy:

• Patient information - Day 4 INR Instructions / Blood Monitoring

4. Refer to warfarin dosing table for recommended dosing

5. Repeat INR on day six or seven and adjust the dose appropriately:

• if the INR is not yet in the therapeutic range increase the dose by 1 or 2 mg at most

• if the INR is in the therapeutic range continue with the same dose

• if the INR is above the range reduce the dose or consider withholding the dose if INR is >3.5

6. Repeat INR on day nine or ten

Fax Haematology Service Referral Form to Haematology (06) 350 8551 to arrange six-week follow up appointment to discuss

duration of anticoagulation therapy.

If there are any concerns regarding patient therapy consult with Haematology.

37. Review by specialist team

Patients are reviewed by Haematology six weeks post DVT to determine ongoing need and duration of anticoagulation therapy.

38. Review by specialist team

Patients are reviewed by Haematology six weeks post DVT to determine ongoing need and duration of anticoagulation therapy.

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 15 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

Deep Vein Thrombosis (DVT)

Provenance Certificate

Overview

Overview | Editorial methodology | References | Contributors | Disclaimers

This document describes the provenance of MidCentral District Health Board’s Deep Vein Thrombosis (DVT) pathway. This pathway is regularly updated to include new, quality-assessed evidence, and practice-based knowledge from expert clinicians. Please see the Editorial Methodology section of this document for further information.

This localised pathway was last updated in June 2018.

For information on changes in the last update, see the information point entitled ‘Updates to this care map’ on each page of the pathway.

One feature of the “Better, Sooner, More Convenient” (BSMC) Business Case, accepted by the Ministry of Health in 2010, was the development of 33 collaborative clinical pathways

(CCP). The purpose of implementing the CCP Programme in our DHB is to:

• Help meet the Better Sooner More Convenient Business Case aspirational targets, particularly the following:

o Reduce presentations to the Emergency Department (ED) by 30%

o Reduce avoidable hospital admissions to Medical Wards and Assessment Treatment and Rehabilitation for over-65-year-olds by 20%

o Reduce poly-pharmacy in the over-65-year-olds by 10%

• Implement a tool to assist in planning and development of health services across the district, using evidence-based clinical pathways.

• Provide front line clinicians and other key stakeholders with a rapidly accessible check of best practice;

• Enhance partnership processes between primary and secondary health care services across the DHB.

To cite this pathway, use the following format:

Map of Medicine. Medicine. MidCentral District View. Palmerston North: Map of Medicine; 2014 (Issue 1).

Editorial methodology

This care map was based on high-quality information and known Best Practice guidelines from New

Zealand and around the world including Map of medicine editorial methodology. It has been checked by

individuals with front-line clinical experience (see Contributors section of this document).

Map of Medicine pathways are constantly updated in response to new evidence. Continuous evidence

searching means that pathways can be updated rapidly in response to any change in the information

landscape. Indexed and grey literature is monitored for new evidence, and feedback is collected from

users year-round. The information is triaged so that important changes to the information landscape are

incorporated into the pathways through the quarterly publication cycle.

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 16 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

References

This care map has been developed according to the Map of Medicine editorial methodology. The content of this care map is based on high-quality guidelines and practice-based knowledge provided by contributors with front-line clinical experience. This localised version of the evidence-based, practice- informed care map has been peer-reviewed by stakeholder groups and the CCP Programme Clinical Lead.

1 Contributors representing the DVT Collaborative Clinical Pathway Working Group – MidCentral DHB, (2013)

2 Deep vein thrombosis community pathway – MidCentral DHB, (2008)

3

Schutgens, R. E. G.; Haas, F. J. L. M.; Gerritsen, W. B. M.; Van Der Horst, F.; Nieuwenhuis, H. K.; Biesma, D. H. The usefulness of five d-dimer assays in the exclusion of deep venous thrombosis. Journal of Thrombosis and Haemostasis vol. 1 issue 5 May 2003. p. 976-981

4 Oger E, Leroyer C, Bressollette L, et al Evaluation of a new, rapid, and quantitative D-Dimer test in patients with suspected pulmonary embolism. Am J Respir Crit Care Med. 1998 Jul; 158(1):65-70.

5 Map of Medicine (MoM) Clinical Editorial team and Fellows. London: MoM; 2010

6

Guyatt, G., Akl, E., Crowther, M., Gutterman,D., & Schuünemann, H. (2012).Executive Summary; Antithrombotic Therapy and Prevention of Thrombosis: American College of Chest Physicians Evidence- Based Clinical Practice Guidelines. CHEST Journal, 141(2_suppl), 7S-47S.

7

Scottish Intercollegiate Guidelines Network. (2010, December 1). Prevention and management of venous thromboembolism. Quick reference guide. Retrieved May 16th, 2013, from www.sign.uk: http://www.sign.ac.uk/pdf/sign122.pdf

Contributors

MidCentral DHB’s Collaborative Clinical Pathway editors and facilitators worked with clinical stakeholders such as front-line clinicians and pharmacists to gather practice-based knowledge for its care maps.

The following individuals contributed to the update of this care map:

• Dr Paul Harper, Haematologist (Secondary Care Clinical Lead)

• Dr Paul Cooper, General Practitioner (Primary Care clinical lead)

• Daryl Pollock, CNS, Thrombosis and Haemostasis, MidCentral Health

• Beth McPherson, Clinical Nurse Specialist Lead, Acute Care, Health Care Development

• Kim Vardon, Clinical Pathways Programme, CPHO (Pathway Editor)

The following individuals contributed to the original development of this care map:

• Dr Paul Harper, Haematologist (Secondary Care Clinical Lead)

• Dr Paul Cooper, General Practitioner (Primary Care clinical lead)

• Daryl Pollock, CNS, Thrombosis and Haemostasis, MidCentral Health

• Jenni Olivier, Nurse Coordinator

• Karen Lombard, Pharmacist

• Dr David Ayling, Primary Health Care Practitioner (Facilitator)

• Jess Long, Programme Manager, Collaborative Clinical Pathways Programme (Pathway editor)

DEEP VEIN THROMBOSIS (DVT) April 2018 Page 17 of 17

This map was published by MidCentral District. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.

Disclaimers

Clinical Board Central PHO, MidCentral DHB

It is not the function of the Clinical Board Central PHO, MidCentral DHB to substitute for the role of the

clinician, but to support the clinician in enabling access to know-how and knowledge. Users of the Map

of Medicine are therefore urged to use their own professional judgement to ensure that the patient

receives the best possible care. Whilst reasonable efforts have been made to ensure the accuracy of

the information on this online clinical knowledge resource, we cannot guarantee its correctness and

completeness. The information on the Map of Medicine is subject to change and we cannot guarantee

that it is up-to-date.