Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 13 Sept 2026Clinical review pending
Saved on this device
!
Bleeding or clot progression
Major haemorrhage, new PE signs or progression to phlegmasia demands immediate reassessment.
Action: Resuscitate and involve haematology, vascular or PE specialists for interruption, reversal or urgent clot treatment.
Synopsis
Select, dose and review DVT anticoagulation while respecting anatomy, recurrence, bleeding and special populations.
Confirmed proximal DVT requires therapeutic anticoagulation for at least 3 months; reassess recurrence risk, bleeding and preference at 3 months before stopping, changing or extending treatment.
Take FBC, renal and hepatic function, PT and APTT before treatment; active significant bleeding contraindicates anticoagulation, but do not await results before indicated interim therapy. In pregnancy, use therapeutic LMWH based on booking or early-pregnancy weight through pregnancy and at least 6 weeks postpartum, for at least 3 months total.
Isolated distal DVT has no universal anticoagulation rule: assess symptoms, extension risk, cancer and bleeding; if untreated, repeat clinical assessment and whole-leg ultrasound after 1 week. At weight below 50 kg or above 120 kg, monitor therapeutic anticoagulant levels regularly with specialist or agreed-protocol input; established triple-positive APS requires LMWH with a VKA for at least 5 days and until INR is at least 2.0 twice, then VKA alone.
Key red flags
Haemodynamic bleeding, intracranial symptoms or a major haemoglobin fall requires emergency review.
New breathlessness, chest pain, haemoptysis, syncope or hypotension suggests PE or treatment failure.
Increasing cyanosis, tense swelling, sensory loss or weakness suggests phlegmasia.
Proximal anatomy
Popliteal, femoral or iliac thrombosis normally requires prompt treatment for at least three months.
Treatment failure
New objective clot despite reported adherence requires dose, interaction, absorption and compliance checks.
Major bleeding
Shock, intracranial signs, overt gastrointestinal blood loss or falling haemoglobin requires emergency haemorrhage control.
Investigation priorities
01
Compression or whole-leg ultrasoundFirst step
Confirm DVT and define proximal or distal extent.
Management branches
Worked case: provoked proximal DVTTreat and review
A stable adult has femoral DVT after surgery, acceptable bleeding risk and CrCl 72 mL/min.
Confirm extent, screen for PE or limb threat and take baseline blood tests.
Discuss apixaban or rivaroxaban and prescribe the entire licensed acute sequence.
Key medicines
ApixabanGive 10 mg orally twice daily for 7 days, then 5 mg twice daily; if extended prevention is chosen after 6 months, give 2.5 mg twice daily.Contraindicated in active significant bleeding or hepatic coagulopathy with bleeding risk. Use cautiously at CrCl 15–29 and not below 15 mL/min or in dialysis. Avoid pregnancy; breastfeeding requires stopping either breastfeeding or apixaban. In active cancer, assess tumour site, anticancer and other drug interactions, and bleeding risk before selection. Review at three months and annually if continued.
RivaroxabanGive 15 mg orally twice daily with food for days 1–21, then 20 mg once daily with food. Only when CrCl is 15–49 mL/min, after day 21 when 20 mg once daily would otherwise apply, consider 15 mg once daily if assessed bleeding risk outweighs recurrent DVT or PE risk. After at least 6 months, extended prevention is 10 mg once daily, or 20 mg when recurrence risk remains high.Contraindicated with active bleeding, hepatic coagulopathy, pregnancy and breastfeeding. Use cautiously at CrCl 15–29 and not below 15 mL/min. The optional 15 mg maintenance reduction for CrCl 15–49 mL/min is based on pharmacokinetic modelling and has not been studied in this clinical setting. In active cancer, assess tumour site, anticancer and other drug interactions, and bleeding risk before selection; review at three months.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 13 Sept 2026; clinical approval remains outstanding.