Ashish Gupta, MD, outlines his ABCs for confronting and treating patients with acute deep vein thrombosis (DVT) of the lower extremity, and how he developed his dictums.
A is for “anticoagulation” for not more than six months of duration. Rationale: At the six-month mark, if the patient is still on anticoagulation, there has to be a reassessment and discussion between patient and healthcare personnel over whether the patient really needs further treatment with anticoagulation. The American Society of Hematology (ASH) guidelines define the treatment period as “initial management” (first five to 21 days), “primary treatment” (first three to six months), and “secondary prevention” (beyond the first three to six months). The guidelines favor shorter courses of anticoagulation (three to six months) associated with a transient risk factor. The guidelines suggest indefinite anticoagulation for most patients with unprovoked DVT associated with a chronic risk factor.
B is for “Be active, Be ambulatory.” Rationale: Many people are told to take it easy, such as limit their walking and stay on bed rest. Both are myths. Both the American College of Chest Physicians and American Physical Therapy Association (APTA) guidelines recommend early ambulation for patients with acute DVT.
C is for “Consider compression stockings or ace wraps.” Rationale: Requirement for compression will be dependent on extent and location of DVT. Per ASH, select patients benefit from compression stockings to help with edema and pain associated with acute DVT.
It is a well-established science that for general treatment of acute DVTs, three to six months of standard anticoagulation, early ambulation, and compression stockings for certain scenarios are recommended.
However, after 17 years of solo private practice in a community setting, I find that these dictums are not being followed the majority of the time.
As vascular surgeons are not the first-line people in treating and diagnosing the majority of DVTs, my personal experience has been that many patients in a wide variety of scenarios are not taken off their anticoagulation (rather they are led to believe that they have to stay on them forever).
Instead of early ambulation, they are told to limit their ambulation post-diagnosis, and only few get their compression stockings prescribed when indicated. Another of my observations has been that patients have an inherent feeling of security against DVTs when they are taking blood thinners indefinitely. And when told that you can get off it, they look at you with suspicion and doubt.
Furthermore, I have seen many patients (who have DVT as one of their many diagnoses) admitted in long-term acute care facilities (LTACs) and nursing homes who keep getting their anticoagulation for beyond six months, despite rebounding between hospitals and back to their LTACs and nursing homes. It’s practically impossible for innumerable rotating physicians, consultants, and emergency room physicians to stop their anticoagulation as they don’t have a total picture of the patient. And their mindset is also: why rock the boat! It is easier to keep the anticoagulation rather than take patients off.
Then we also have those patients who move to another city and establish care with a new primary care provider (PCP). And if they have been on anticoagulation with the initial physician, the new PCP continues the same anticoagulation regimen.
On a personal front, I have had several patients over the years who have been on warfarin for several years for a remote DVT (supra- and infrapopliteal), and now they don’t have veins from which to draw blood. When admitted to hospital, they end up getting central lines as they don’t have any peripheral venous access. Also, people with chronic DVT diagnoses found during hospital admissions keep being treated with anticoagulation.
Then there are those several patients who have been on direct oral anticoagulants (DOACs) that don’t require blood testing, but they are paying a lot of money unnecessarily for their medications. They frequently mention that they can’t afford these expensive medications, and ask whether I have samples for them. Finally, how can we forget those patients who get into bleeding complications that are catastrophic. It is obvious that unnecessary anticoagulation is a major risk that patients take while pharmaceutical companies reap their profits.
As March is national DVT Awareness Month, I have been thinking about how to make the treatment algorithm simple for all. This includes patients, their family members, medical students, residents, fellows, practicing doctors (PCPs, hematologists, cardiologists, pulmonologists, internists, vascular surgeons, interventional radiologists), nurse practitioners, physician assistants, and anyone who comes in contact with DVTs. And what better way than using a simple acronym? In the spirit of global awareness and education, I came up with a simple catchy phrase/triad: “Dr. Ashish Gupta’s ABCs for treatment of lower-extremity acute DVTs.”
This acronym is by no means discriminating between treatment of supra- and infrapopliteal DVTs, as some do treat infrapopliteal DVTs, on a case-by-case basis, with anticoagulation and/or with follow-up venous duplex for evaluation of propagation. Even if someone is treated for infrapopliteal DVT, their anticoagulation should be stopped by six months at the latest, if not sooner. The hope is to make this acronym a framework for all involved in the treatment of DVTs in order to raise awareness of the ABCs, and not simply over treat.
I strongly believe that implementation of this acronym will help all involved remember easily how to manage DVTs, empower patients and caregivers, and will avoid unnecessary use of anticoagulation, avoid costs, and reduce major complications that can come from diagnosis of DVT. The implications during DVT Awareness Month of this acronym can be exponentially beneficial and fruitful in terms of best practices, where not only healthcare providers, but even patients and their family members can remind themselves at six months whether they need anticoagulants anymore.
Ashish Gupta is a board-certified vascular and endovascular surgeon practicing in Wyandotte, Michigan, as a solo private practitioner since 2005.