At the June 26th 2014 Pharmacy and Therapeutics Committee meeting, discussion ensued with the Cardiologist and Hematologist members of the committee regarding the treatment of Deep Vein Thrombosis (DVT) on an outpatient basis. This concept is not new, and is reviewed in the 2012 CHEST Antithrombotic Therapy and Prevention of Thrombosis 9th ed. Guidelines, UpToDate and other references. The issue is that we occasionally find patients who have no other reason to be hospitalized except that they are waiting for their INR to become therapeutic. As referenced, options for outpatient treatment include bridging with Low Molecular Weight Heparin (LMWH) until the INR becomes therapeutic. Additionally, section 5.5 of the Chest 2012 guidelines recommends early discharge over standard discharge for patients with low risk PE whose home circumstances are adequate after five inpatient days.
There are four criteria that may be used to help identify patients who are NOT candidates for outpatient treatment:
- Presence of massive DVT (eg, iliofemoral DVT)
- Presence of symptomatic pulmonary embolism
- High risk of bleeding with anticoagulant therapy
- Presence of comorbid conditions or other factors that warrant in-hospital care
While initial treatment is recommended at home over hospital, this recommendation is conditional on the adequacy of home circumstances. Our intent is to evaluate a pathway at the September Pharmacy and Therapeutics Committee meeting that will aid physicians in the decision process. If your patient does not meet the criteria to remain in the hospital, we urge you to consider outpatient bridging therapy with LMWH and utilizing the Anticoagulation Clinic at Centegra.