Home therapy for Acute DVT in the leg! Is it safe in all countries?

Home therapy for DVT is convenient and it gives freedom with safety to treat the patients coming in the out patient clinic without admission in to the hospitals and additional burden hospital beds and expenditure to the family.

In patients with DVT, home treatment was associated with a better outcome than treatment in the hospital. Current guidelines of antithrombotic therapy recommend initial treatment of patients with acute deep venous thrombosis (DVT) with low-molecular-weight heparin (LMWH), fondaparinux, or unfractionated heparin (UFH) over no such initial therapy.¹ A number of studies comparing LMWH administered at home (without hospital admission or after early discharge) with UFH in the hospital suggested that home therapy may be associated with improved outcome and better quality of life.^{2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12} Hence, in DVT patients with adequate home circumstances, current guidelines recommend that most patients with DVT be initially treated at home rather than in the hospital.¹ However, many physicians are still concerned about the safety of home therapy because even with adequate anticoagulation, some patients may present with symptomatic pulmonary embolism (PE), recurrent DVT, major bleeding complications, or even death.

The RIETE (Registro Informatizado de la Enfermedad TromboEmbólica) registry is an ongoing, international (Spain, France, Italy, Israel, Germany, Switzerland, Republic of Macedonia, and Brazil), multicenter, prospective registry of consecutive patients presenting with symptomatic acute venous thromboembolism (VTE). It started in Spain in 2001, and some years later, the database was translated into English to expand the Registry to other countries, with the aim to help physicians worldwide select the most appropriate therapy for their patients. Data from this registry have been used to evaluate outcomes after acute VTE, such as the frequency of recurrent VTE, major bleeding, and mortality, and risk factors for these outcomes.^{13, 14,15 and 16} The current analysis compared the outcome of outpatients with acute DVT of the lower limbs within the first week of anticoagulation according to initial therapy at home or in the hospital.

References

1. C. Kearon, E.A. Akl, A.J. Comerota, P. Prandoni, H. Bounameaux, S.Z. Goldhaber et al. American College of Chest Physicians. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141 (Suppl) (2012), pp. e419S–e494S

2. M. Bakker, P.J. Dekker, E.A. Knot, P.F. van Bergen, J.J. Jonker Home treatment for deep venous thrombosis with low-molecular-weight heparinLancet, 2 (1988), p. 1142

3. M. Levine, M. Gent, J. Hirsh, J. Leclerc, D. Anderson, J. Weitz et al.A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med, 334 (1996), pp. 677–681

4.M.M. Koopman, P. Prandoni, F. Piovella, P.A. Ockelford, D.P. Brandjes, J. van der Meer et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. The TASMAN Study Group N Engl J Med, 334 (1996), pp. 682–687

5. I.G. Schraibman, A.A. Milne, E.M. Royle Home versus in-patient treatment for deep vein thrombosisCochrane Database Syst Rev, 2 (2001), p. CD003076

6. R. Othieno, M. Abu Affan, E. Okpo Home versus in-patient treatment for deep vein thrombosisCochrane Database Syst Rev, 3 (2007), p. CD003076

7. W. Ageno, R. Grimwood, S. Limbiati, F. Dentali, L. Steidl, P.S. Wells Home-treatment of deep vein thrombosis in patients with cancer Haematologica, 90 (2005), pp. 220–224

8. S. Siragusa, C. Arcara, A. Malato, R. Anastasio, M.R. Valerio, F. Fulfaro et al. Home therapy for deep vein thrombosis and pulmonary embolism in cancer patients Ann Oncol, 16 (Suppl 4) (2005), pp. 136–139

9. S.R. Kahn, V. Springmann, S. Schulman, J. Martineau, J.A. Stewart, N. Komari et al. Management and adherence to VTE treatment guidelines in a national prospective cohort study in the Canadian outpatient setting. The Recovery Study. Thromb Haemost, 108 (2012), pp. 493–498

10. M. Winter, D. Keeling, F. Sharpen, H. Cohen, P. Vallance, Haemostasis and Thrombosis Task Force of the British Committee for Standards in Haematology Procedures for the outpatient management of patients with deep venous thrombosis. Clin Lab Haematol, 27 (2005), pp. 61–66

11. V. Snow, A. Qaseem, P. Barry, E.R. Hornbake, J.E. Rodnick, T. Tobolic, American College of Physicians; American Academy of Family Physicians Panel on Deep Venous Thrombosis/Pulmonary Embolism et al. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians Ann Intern Med, 146 (2007), pp. 204–210

12. J.D. Douketis. Treatment of deep vein thrombosis. What factors determine appropriate treatment?Can Fam Physician, 51 (2005), pp. 217–223