How to manage outpatients with deep vein thrombosis?

Much interest has been focused on low molecular weight heparins (LMWH), lig ht weight fragments of standard heparin, for the management of deep vein th rombosis (DVT) without pulmonary embolism (PE). LMWHs offer several advanta ges: predictable anticoagulant activity, better bioavailability, longer hal f-life, better patient and caretaker comfort, safety and efficacy at least comparable to continuous intravenous heparin. Ambulatory treatment is quite attractive and a large number of patients with DVT are now being managed a s outpatients. There are however certain precautions which must be taken to avoid unsatisfactory anticoagulation and subsequent consequences which hav e nevertheless been shown to be exceptional in well-designed and well-condu cted trials excluding patients with high risk for hemorrhage and based on a ttentive medical control. The purpose of this review is to propose clear and simple protocols for eve ryday practice aimed at a global diagnostic and therapeutic management of v enous thromboembolism. The review of the literature draws attention to the need for confirmation of the clinical suspicion of DVT, practical applicati on of the anticoagulant treatment, and the importance of the etiology searc h in order to avoid missing a congenital or acquired state of thrombophilia or an occult cancer revealed by DVT. Half of all cases of thrombosis are c aused by these two etiologies. In addition, with the development of noninva sive methods for diagnosing DVT, the efficacy of clear therapeutic regimens and the simplification of coagulation tests warrant outpatient management in many cases of DVT in compliance with certain rules of good clinical prac tice : confirmation of the diagnosis and regular treatment controls. An ess ential element is the close collaboration between the patient, the physicia n, the nursing staff, the laboratory and the pharmacist.