NICE updated their guidelines on the investigation and management of venous thromboembolism (VTE) in 2020. Some of the key changes include recommending the following:
the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE
the use of DOACs in patients with active cancer, as opposed to low-molecular weight heparin as was the previous recommendation
routine cancer screening is no longer recommended following a VTE diagnosis
Choice of anticoagulant
the big change in the 2020 guidelines was the increased use of DOACs
apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a DVT
instead of using low-molecular weight heparin (LMWH) until the diagnosis is confirmed, NICE now advocate using a DOAC once a diagnosis is suspected, with this continued if the diagnosis is confirmed
if neither apixaban or rivaroxaban are suitable then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin)
if the patient has active cancer
previously LMWH was recommended
the new guidelines now recommend using a DOAC, unless this is contraindicated
if renal impairment is severe (e.g. < 15/min) then LMWH, unfractionated heparin or LMWH followed by a VKA
if the patient has antiphospholipid syndrome (specifically ‘triple positive’ in the guidance) then LMWH followed by a VKA should be used