Consensus on the Management of the Clinical Challenges of Venous Thromboembolism in Special Situations

Spanish multidisciplinary VTE expert panel (Catalonia) · 2025 · Europe

Source and licence

Authors: Cristina Marzo, Teresa Solanich, Dolors Tassies et al.
Title: Consensus on the Management of the Clinical Challenges of Venous Thromboembolism in Special Situations
Journal: Thrombosis and Haemostasis, 2025
DOI: 10.1055/a-2595-1811
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC12457007

Licence statement of the original publication

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Recommendations

In provoked VTE with a major transient risk factor, 3 months of anticoagulation treatment is recommendedGrade I, A recommendation
In patients who cannot receive a DOAC, a 3-month treatment with LMWH could be considered over VKA, as LMWH was found to reduce the PTS incidence and to show a higher patient satisfaction compared with VKAGrade II, C recommendation
In unprovoked VTE with low and moderate bleeding risk, extended anticoagulation beyond 3 months, with periodic reassessment of bleeding risk, is recommendedGrade I, A recommendation
In patients with VTE within the context of malignant neoplasia, anticoagulant treatment of at least 6 months is recommendedGrade I, A recommendation
LMWH is preferred over DOAC for initial and long-term treatment in cancer patients with GI or GU tumors, high risk for gastrointestinal bleeding, unstable clinical situations, such as low platelet count, nausea, and vomiting, severe renal insufficiency, and a risk of expected drug interactions with the anti-cancer therapyGrade I, B recommendation
The presence of RVT is not a strong risk factor of recurrence and should, therefore, not condition the duration of treatmentGrade I, B recommendation
The indication for performing a duplex ultrasound on finalizing anticoagulant treatment is not aimed at prolonging treatment if RVT is detected, but rather, in the case of symptomatic recurrence, it is performed to determine if this is a sequela or a new thrombotic episodeGrade I, B recommendation

When Should Thromboprophylaxis with Low Molecular Weight Heparin (LMWH) be Initiated in Pregnant Women with a History of VTE?

In pregnant women with a history of VTE who are not receiving long-term anticoagulation, the guidelines recommend that all of these women should receive postpartum thromboprophylaxis with LMWH. 19 20 21 22 In the guidelines of the American Society of Hematology (ASH), the grade of recommendation is strong, with low certainty of evidence regarding its effects. 19 Thromboprophylaxis should continue up to at least 6 weeks postpartum (level of evidence 2B and Grade B recommendation). 20 21

Recommendations

In pregnant women with a history of VTE not receiving long-term anticoagulation: • If the VTE was associated with a major transitory risk factor and in the absence of other risk factors, prophylaxis is recommended only in the postpartum period (Grade III, B recommendation). • If the VTE was unprovoked, related to estrogens, or recurrent, it is recommended to initiate prophylaxis with LMWH in the first trimester and maintain this until at least 6 weeks postpartumGrade II, B recommendation
In pregnant women with a history of VTE not receiving long-term anticoagulation therapy: • The most adequate dose of LMWH to achieve antithrombotic prophylaxis is not well defined. Although the standard prophylactic dose of LMWH seems to be effective in antithrombotic prophylaxis ante- and postpartum (Grade II, B recommendation), it remains to be determined whether the intermediate doses might be more effective in the postpartum period.

What is the Best Therapeutic Strategy in Patients with Severe Renal Insufficiency (Glomerular Filtration Rate [GFR] <30 mL/min)? And in Patients with a GFR of 15–20 mL/min?

This lack of scientific evidence means that the main clinical practice guidelines, which advocate for the use of DOAC over VKA in VTE (Grade 1A), include patients with a GFR <30 ml/min as an exception to this rule (Grade 5E), as is the case with the 2019 European Society of Cardiology (ESC) guidelines, which do not recommend the use of DOAC in these patients. 30 31

Recommendations

In patients with RI (GFR 20–30 mL/min) both DOAC (apixaban, rivaroxaban, edoxaban) as well as LMWH adjusted according to the SmPCs or VKA can be considered. Treatment should be individualized according to the characteristics and preferences of the patientsGrade V, C recommendation
In patients with severe RI (GFR <15 mL/min) none of the DOACs are recommended or are contraindicated (Grade V, E recommendation), and in cases requiring anticoagulation, LMWH or VKA adjusted according to the SmPC and with close monitoring should be consideredGrade V, B recommendation
The use of anti-Xa in patients with severe RI is controversial and should not be routinely usedGrade V, C recommendation
Taking all the above into account, the use of a dose of LMWH adjusted to the weight of the patient without establishing a maximum limit is recommended for the treatment of VTE in obese patients with weights greater than 100 kgGrade III, B recommendation
In patients with obesity, DOAC can be used when the BMI is <40 kg/m 2 or in individuals with a weight <120 kgGrade III, C recommendation
If treatment with DOAC is unavoidable, standard doses of rivaroxaban or apixaban can be used in patients with a BMI >40 kg/m 2 or in individuals with a weight >120 kgGrade V, C recommendation
It is suggested not to use DOAC for the treatment or prevention of VTE in the acute phase following bariatric surgery, and instead, the use of parenteral anticoagulation in the post-surgical phase is recommendedGrade IV, B recommendation
In patients with cancer-associated thrombosis and obesity, the use of LMWH is recommended above the use of DOACGrade III, B recommendation
The indication of anticoagulant treatment in older patients should include comprehensive geriatric assessment (CGA) to define the frailty profile and monitor the risk of recurrence and bleeding, and treatment adherence. Among the variables that make up the CGA, comorbidity, polypharmacy, functional status, cognitive status, and social support are of special relevance. CGA includes the planning of geriatric interventions specifically aimed at potentially improvable or reversible risk factorsGrade IV, C recommendation
It is recommended to reduce polypharmacy with the aim of decreasing potential interactions with oral anticoagulants. Avoid pharmacokinetic interactions between DOAC and CYP3A4 or P-glycoprotein inhibitors/inducers. In cases with polypharmacy and a high risk of drug interactions, the use of LMWH is preferred, with a periodic reassessment of the risk–benefit of the treatmentGrade IV, C recommendation
Renal function must be monitored in older patients to adequately adjust the dosage of DOAC or LMWH. DOACs are contraindicated if creatinine clearance is <15 mL/minGrade IV, B recommendation
In patients with little mobility and/or risk of falls, measures can be taken to improve their physical status and adapt the environment to attempt to avoid fallsGrade V, C recommendation
To guarantee treatment adherence, the autonomy of treatment management of the patient and/or the identification of a responsible caregiver must be assessed. It is important for the patient and/or main caregiver to receive clear information regarding the disease and the treatmentGrade V, C recommendation
In older patients with a high risk of bleeding or low risk of thrombotic recurrence (VTE secondary to a transitory risk factor or distal DVT) 3 months of treatment should be consideredGrade III, C recommendation
If the risk of bleeding is not high, in older patients with idiopathic or cancer-associated VTE, long-term treatment should be considered with periodic risk–benefit reassessmentsGrade I, B recommendation
In long-term treatment (>6 months) with apixaban and rivaroxaban, dose reduction is suggestedGrade II, C recommendation

Primary Thromboprophylaxis in Ambulatory Cancer Patients with Systemic Antineoplastic Treatment

• VTE risk assessment should be based on validated RAMs such as the KRS, COMPASS-CT score, or CT nomogram (III, C). An estimated risk of VTE >8–10% at 6 months is suggested as threshold for discussing primary thromboprophylaxis (II, C).• For ambulatory pancreatic cancer patients on first-line systemic anticancer treatment, LMWH given at a higher dose for a maximum of 3 months may be considered (II, C).• In ambulatory cancer patients starting systemic anticancer treatment who have a high thrombosis risk, apixaban, rivaroxaban, or LMWH may be considered for primary thromboprophylaxis for a maximum of 6 months (I, B).• Where concerns of DOAC safety exist and the patient is perceived as having clinically important risk for VTE, LMWH at conventional primary thromboprophylaxis dosing may be administeredII, C
• Routine pharmacologic thromboprophylaxis should not be offered to all outpatients with cancer (strong recommendation).• High-risk outpatients with cancer (Khorana score of 2 or higher before starting a new systemic chemotherapy regimen) may be offered thromboprophylaxis with apixaban, rivaroxaban, or LMWH provided there are no significant risk factors for bleeding and no drug interactions (moderate recommendation).• Patients with multiple myeloma receiving thalidomide- or lenalidomide-based regimens with chemotherapy and/or dexamethasone should be offered pharmacologic thromboprophylaxis with either aspirin or LMWH for lower risk patients and LMWH for higher risk patientsstrong recommendation
• VTE risk evaluation based on Khorana score of patients with cancer receiving/starting systemic therapy for their cancer.• Consider anticoagulant prophylaxis (LMWH or DOAC) for up to 6 months or longer if risk persists in patients with intermediate or high risk for VTE (Khorana score ≥2). Patients with gastric or gastroesophageal tumors are at increased risk for hemorrhage with DOAC.
• Primary pharmacological prophylaxis of VTE with LMWH (grade 1A) or with DOAC (rivaroxaban or apixaban; grade 1B) is indicated in ambulatory patients with locally advanced or metastatic pancreatic cancer treated with systemic anticancer therapy and who have a low risk of bleeding.• Primary prophylaxis with DOAC (rivaroxaban or apixaban) is recommended in ambulatory patients who are receiving systemic anticancer therapy and are at intermediate to high risk of VTE, identified by a validated risk assessment model (i.e., a Khorana score ≥2), and not actively bleeding or not at a high risk for bleeding (grade 1B).• In patients with myeloma treated with immunomodulatory drugs combined with steroids or other systemic anticancer therapies, VTE primary pharmacological prophylaxis is recommended (grade 1A); in this setting, oral anticoagulants (vitamin K antagonists at low or therapeutic doses and apixaban at prophylactic doses), LMWH at prophylactic doses, or low-dose aspirin (100 mg daily) can be used and have shown similar effects with regard to preventing VTE (grade 2B). Values and preferences: subcutaneous injections.
• Classification of risk based on validated risk assessment tool (i.e., Khorana score) complemented by clinical judgment and experience.• Low risk: no thromboprophylaxis recommended (over LMWH)/suggested (over DOAC).• Intermediate risk: apixaban/rivaroxaban or no thromboprophylaxis suggested.• High risk: apixaban/rivaroxaban or LMWH suggested.• For multiple myeloma patients receiving lenalidomide-, thalidomide-, or pomalidomide-based regimens, the ASH guideline panel suggests using low-dose ASA, fixed low-dose VKA, or LMWH.
• It is recommended to use a validated RAM to assess VTE risk (level of evidence: grade 2C).• Routine thromboprophylaxis is not recommended in ambulatory patients with cancer (level of evidence: grade 1B).• Pharmacological thromboprophylaxis with LMWH or DOACs may be considered in high-risk ambulatory cancer patients, such as advanced pancreatic cancer, NSCLC with ROS-1 or ALK rearrangement, patients with a Khorana score ≥2 or considered high risk based on a validated RAM, starting of receiving systemic therapy, and no contraindications to anticoagulation and low risk of bleeding. Pharmacological thromboprophylaxis is suggested at least 12 weeks after the initiation a new systemic therapy. Perform DDI assessment with DOAC. Discuss with patient potential risk and benefitslevel of evidence: grade 1B

Recommendations

The evaluation of risk of VTE should be based on the use of any of the validated RAM at the time the patient initiates systemic antineoplastic treatmentGrade III, C recommendation
As a threshold for considering primary thromboprophylaxis, an estimated risk of VTE of >8 to 10% at 6 months is suggestedGrade II, C recommendation
Primary pharmacological prophylaxis of VTE should be performed with LMWH (Grade I, A recommendation) or with DOAC (rivaroxaban or apixaban; Grade II, B recommendation) in ambulatory pancreas cancer patients with locally advanced or metastasis treated with systemic antineoplastic therapy and who have a low risk of bleeding.
Consider performing pharmacological thromboprophylaxis with LMWH or DOAC in other patients with high risk, such as those with non-small cell lung cancer with ROS-1 or ALK rearrangement, and patients classified as high risk according to a validated RAM, who are receiving systemic therapy, without contraindications for anticoagulation and with low risk of bleedingGrade II, B recommendation
Consider performing at least 12 weeks of thromboprophylaxis after the initiation of a new systemic therapyGrade II, B recommendation
Special caution is suggested with the use of DOAC in patients with a high risk of bleeding (gastrointestinal/genitourinary tumors, and comorbidities which increase the risk) and in patients with potential pharmacological interactionsGrade I, B recommendation

Contents of the original publication

The section headings of the original.

Introduction
Methodology
Results
Duration of VTE Treatment and the Role of Thrombus Recanalization
Prophylaxis of Venous Thromboembolism (VTE) in Pregnancy
Treatment of VTE in Patients with Renal Insufficiency (RI)
Treatment of VTE in Patients with Extreme Body Weight
Therapeutic Management of Older Patients with Pluripathology and Polymedication
Primary Thromboprophylaxis in Ambulatory Cancer Patients with Systemic Antineoplastic Treatment

A question about this guideline?

Medelix answers clinical questions from guidelines and studies – every statement with its source.

Are you the rights holder and object to this reproduction? Write to contact@medelix.ai and we will take the page down promptly. Imprint