Looking forward in the treatment of deep-vein thrombosis

Clinical guidelines developed by the American College of Chest Physicians (ACCP) for the management of venous thromboembolism (VTE) are based on current evidence from randomized clinical trials and amended in response to emerging results. The standard treatment for VTE comprises in-hospital treatment with dose-adjusted unfractionated heparin (UFH) for a minimum of 5 days and oral anticoagulants for at least 3 months. Recent clinical studies show that subcutaneous low-molecular-weight heparins (LMWHs) in fixed doses according to body weight are as effective and safe as intravenous UFH in the initial treatment of deep-vein thrombosis, with or without pulmonary embolism. There is also evidence that the optimal duration of secondary thromboprophylaxis depends on assessable thromboembolic risk factors. The 1998 ACCP guidelines take account of this new evidence by advocating LMWHs as an alternative to standard UFH for the initial treatment of VTE and risk stratification of patients to guide duration of secondary thromboprophylaxis. Outpatient treatment of VTE with LMWHs has been shown to be feasible and is increasingly used in clinical practice, offering substantial economic benefits. Certain LMWHs appear to be effective at a once-daily dose. Evidence is now emerging that may clarify the role of inferior vena cava filters and thrombolysis in VTE management. Future versions of the ACCP guidelines may be expected to reflect new data from ongoing trials.