Management of patient with possible VTE in emergency medicine guideline

Q & A algorithm

Q & A algorithm

Score 1 for each of the following:

• Age over 50
• Heart rate over 100
• O2 sats in air 95% or more
• Prior history of DVT/PE
• Recent trauma or surgery (within 4 weeks)
• Haemoptysis
• Exogenous oestrogen
• Clinical signs of DVT

May be elevated with:

• cancer
• infection
• inflammation
• necrosis
• aortic dissection
• pregnancy
• trauma
• recent surgery
• age over 50 (normal range increases with age)

MDcalc (2022) Pulmonary embolism severity indicator

Commence rivaroxaban (unless contra-indicated) for creatinine clearance over 30: 15mg b.d. for 3 weeks and 20mg daily thereafter (unless contraindicated)

• if eGFR below 30ml/min please use warfarin or LMWH as clinically indicated***
• Provide appropriate lifestyle and bleeding advice and education (provide patient leaflet and card).
• Remember to advise the patient to take rivaroxaban with food as this increases bioavailability significantly. 

If contraindications to rivaroxaban - use LMHW and warfarin 

Contraindications to rivaroxaban:

• Patients requiring anticoagulation beyond 12 months
• ***Patients with creatinine clearance below 30ml/min
• Active cancer/chemotherapy patients - commence on a course of LMWH and discuss with oncology
• Pregnant patients:
  • twice daily dose dependant on early pregnancy weight 
  • continue LMWH treatment throughout pregnancy nad breast-feeding for at least 6 months
• Hepatic disease associated with coagulopathy - discuss with consultant of GI registrar
• HIV or hep C patients taking NNRTIs or protease inhibitors
  • commence on dalteparin/warfarin and discuss with the HIV team
  • If unsure about current therapy check clinical letters on Portal (ECS unreliable for re:HIV and hep C meds)
• Co-prescription of strong inhibitors of both cytochrome P450 (CYP) 3A4 and P-glycoprotein (P-gp) (enhanced effectiveness)
  • e.g. azole antifungals (ketoconazole, itraconazole, voriconazole and posaconazole) and HIV protease inhibitors
• Co-prescription with strong CYP3A4 and P-gp inducers (reduced effectiveness)
  • e.g. rifampicin, phenytoin, carbamazepine, phenobarbital or St. John's wort
• In patients at extremes of weight (BMI below 18.5kg/m² or above 30kg/m²)
  • see BNF advice for appropriate measure of renal function for adjusting drug dosages
• For a complete list of drug interactions please see BNF appendix 1 (anticoagulants) and relevant SPC

• Fast initiation as per NHST warfarin chart
• LMWH for at least 5 days
• Provide education around LMWH and warfarin
• Arrange for local follow-up until INR in target range
• Arrange for anticoagulant follow-up thereafter
  • Dundee - via anticoagulation service in Ninewells
  • All other areas via GP

Dalteparin s/cut injection:

Non-pregnancy dosing               

 Pregnancy dosing  

HIV protease inhibitors:

• ritonavir
• atazanavir
• darunavir
• kaletra (lopinavir + ritonavir co-formulated)

NNRTIs:

• efavirenz (also co-formulated as atripla)
• nevirapine
• etravirine
• rilpivirine (also co-formulated as eviplera)

Hep C protease inhibitors:

• telaprevir
• boceprevir