Treatment summary

In the absence of any special circumstances detailed below, patients should be started on apixaban 10mg bd for 7 days, then reduce dose to 5mg bd.

• If direct oral anticoagulant (DOAC) use is contra-indicated, dalteparin 200units/kg od is a suitable alternative for most patients. Dalteparin dose should be reduced to 150 units/kg after 1 month.
• Patients should initially be anticoagulated for 6 months.
• If cancer incurable, or systemic anti-cancer therapy (SACT) ongoing at 6 months, consider extended anticoagulation with:
  • apixaban 2.5mg bd OR
  • dalteparin 150units/kg od. 

Special circumstances:

Patients with primary brain tumours or brain metastases

• In the absence of a recent CNS haemorrhage, benefits of anticoagulation are usually likely to outweigh risks.
• Risk of haemorrhage is increased in patients with glioblastoma multiforme (GBM), melanoma or renal cancer metastases but anticoagulation is still likely to be beneficial.
• Anticoagulation decisions should be discussed with patient's consultant or consultant on call and patient documented in the notes.

Patients with renal impairment

• DOAC - if CrCl>30, treat with apixaban at standard dose.
• Low molecular weight heparin (LMWH) - if CrCl>30, treat with dalteparin at standard dose.
• If CrCl<30, dalteparin with dose modifications or alternative anticoagulation - refer to LUHD antithrombotic guidelines (adults) (only accessible when connected to intranet)

Patients with hepatic impairment

• Severe hepatic impairment (Child-Pugh C; bilirubin >1.5xULN, ALT/AST >2xULN)
  • The risks and benefits of anticoagulation should be discussed.
  • If anticoagulation required treat with dalteparin.
• Coagulopathy (PT ratio or APTT ratio >1.5)
  • Not for anticoagulation.

Patients at risk of significant thrombocytopenia (platelets <50)

• Consider treatment with dalteparin due to the greater flexibility of dosing.

Extremes of weight

Splanchnic vein thrombosis treatment

• See special circumstances of this guidance for detailed advice.

Superficial venous thrombosis treatment

• If thrombosis within 3cm of sapheno-femoral junction, treat with apixaban 5mg bd or dalteparin 200units/kg for 3 months.
• If distal thrombosis measuring >5cm, treat with apixaban 5mg bd or dalteparin 200 units/kg for 6 weeks.
• If distal thrombosis measuring <5cm, treat with topical/oral NSAIDs until pain settles, routine anticoagulation not required.

Inpatient prophylaxis

• Dalteparin 5,000 units od.
• See guidance in extremes of weight.
• See LUHD antithrombotic guidelines (adults) (only accessible when connected to intranet) if CrCl < 30.

Outpatient prophylaxis during SACT in patients with thrombosis risk of >10%

• Khorana score ≥2 or other risk factor for thrombosis.
• Apixaban 2.5mg bd for 6 months or completion of SACT.

Atrial fibrillation (AF), mechanical heart valve

• If contra-indication to current thromboprophylaxis regimen, liaise with relevant consultant.