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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 (



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.

https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/DVT%20Patient%20Information.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Common%20Forms/Herbal%20Medicines%20and%20Warfarin.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Warfarin%20Patient%20Information%20Brochure.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Dabigatran%20Patient%20Information.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Rivaroxaban-Xarelto-Patient-Information-MDHB.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Day%204%20INR%20Instructions.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Patient%20Guide%20-%20Clexane.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Common%20Forms/Te%20Ara%20Whanau%20Ora%20Brochure_UPDATED%20MAY2013.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Provider%20Checklist%20-%20Suspected%20DVT.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Confirmed%20DVT%20Provider%20Discharge%20Checklist.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Wells%20Score%20Sheet.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Ultrasound%20Request%20Form.pdfhttp://www.clinicalculator.com/english/nephrology/cockroft/cca.htmhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Enoxaparin%20(Clexane)%20Administration%20Form.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Clexane%20Dosage%20Calculation%20Table.pdfhttp://www.nzf.org.nz/nzf_1453.html?searchterm=clexane&nzf_1454https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Patient%20Warfarin%20Learning%20Checklist.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Warfarin%20Counselling%20Checklist.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Warfarin%20Dosing%20Table.pdfhttp://www.nzf.org.nz/nzf_1504https://www.nzf.org.nz/nzf_1508https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Haematology%20Service%20Referral%20Form.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Common%20Forms/POAC%20Transfer%20of%20Care%20Handover-2328.pdfhttps://bpac.org.nz/2017/anticoagulants.aspx



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:

http://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Hauora%20Maori%20Forms/Te%20Whare%20Tapa%20Wha.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Hauora%20Maori%20Forms/Cultural%20Issues.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Hauora%20Maori%20Forms/Wh%C4%81naungatanga.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Hauora%20Maori%20Forms/Whanau%20Ora%2C%20Te%20Ara%20Whanau%20Ora%20and%20Navigators.pdfhttp://www.centralpho.org.nz/CollaborativeClinicalPathways/HauoraMaori.aspxhttp://www.centralpho.org.nz/OurServices/M?oriHealth.aspxhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Pacific%20Health%20Forms/Pacific%20Cultural%20Guidelines%20(Central%20PHO).pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Pacific%20Health%20Forms/Fonofale%20model.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Pacific%20Health%20Forms/Cultural%20Protocols%20and%20Greetings.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Pacific%20Health%20Forms/Building%20relationships%20with%20pacific%20patients.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Pacific%20Health%20Forms/Family%20support_Religion_Healing_Hospital.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Pacific%20Health%20Forms/Home%20visits.pdfhttp://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/Pacific%20Health%20Forms/Contact%20info.pdf



• 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




• Rivaroxaban (Xarelto) patient Information



• Te Ara Whānau Ora Brochure

http://apps.centralpho.org.nz/Permalink/MoM/General%20Documents/MoM/Published/General%20Cancer%20docs/MC/Pasifika%20Health%20Final%20Pamphlet%202017%20(003)%20(2).pdfhttp://www.health.govt.nz/publication/ala-moui-pathways-pacific-health-and-wellbeing-2010-2014http://www.health.govt.nz/publication/primary-care-pacific-people-pacific-and-health-systems-approachhttp://www.health.govt.nz/publication/tupu-ola-moui-pacific-health-chart-book-2004http://www.health.govt.nz/our-work/populations/pacific-health/pacific-health-resourceshttp://www.centralpho.org.nz/CollaborativeClinicalPathways/HauoraMaori.aspxhttp://www.centralpho.org.nz/OurServices/PacificHealth.aspxhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/DVT%20Poster%20for%20POAC%20sites%20v1.1.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Provider%20Checklist%20-%20Suspected%20DVT.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Confirmed%20DVT%20Provider%20Discharge%20Checklist.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Wells%20Score%20Sheet.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Ultrasound%20Request%20Form.pdfhttp://www.clinicalculator.com/english/nephrology/cockroft/cca.htmhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Enoxaparin%20(Clexane)%20Administration%20Form.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Clexane%20Dosage%20Calculation%20Table.pdfhttp://www.nzf.org.nz/nzf_1453.html?searchterm=clexane&nzf_1454https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Patient%20Warfarin%20Learning%20Checklist.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Warfarin%20Counselling%20Checklist.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Warfarin%20Dosing%20Table.pdfhttp://www.nzf.org.nz/nzf_1504https://www.nzf.org.nz/nzf_1508https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Haematology%20Service%20Referral%20Form.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Common%20Forms/POAC%20Transfer%20of%20Care%20Handover-2328.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Common%20Forms/POAC%20REFERRAL%20CENTRE%20DETAILS.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/DVT%20Patient%20Information.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Common%20Forms/Herbal%20Medicines%20and%20Warfarin.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Warfarin%20Patient%20Information%20Brochure.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Dabigatran%20Patient%20Information.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Rivaroxaban-Xarelto-Patient-Information-MDHB.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Day%204%20INR%20Instructions.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Patient%20Guide%20-%20Clexane.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Common%20Forms/Te%20Ara%20Whanau%20Ora%20Brochure_UPDATED%20MAY2013.pdf



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 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]

https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Common%20Forms/Primary%20Options%20Acute%20Care%20Eligibility%20Criteria.pdf



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.

https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Wells%20Score%20Sheet.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Ultrasound%20Request%20Form.pdf



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 (



• 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



• 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



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



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



• 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:





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 1.5

• bilirubin >20µmol/L

• PCV



• 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:


32. Precautions

Precautions

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


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

https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Dabigatran%20Patient%20Information.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Day%204%20INR%20Instructions.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Haematology%20Service%20Referral%20Form.pdf



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.


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.

https://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Day%204%20INR%20Instructions.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Warfarin%20Dosing%20Table.pdfhttps://thinkhauorawebsite.blob.core.windows.net/websitepublished/CCP/Resources/Medicine%20Localised%20Pathways/Deep%20Vain%20Thrombosis/Haematology%20Service%20Referral%20Form.pdf



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.



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)

http://www.sign.uk/http://www.sign.ac.uk/pdf/sign122.pdf



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.