Geriatrics - July 2017

MIMS HANDBOOK OF
GERIATRIC MEDICINE

Treatment Approaches

2017/2018

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13/7.5/0111, 0112, 0113, 0114. DYNAVAL CO 80/12,5, 160/12,5, 160/25 mg. Each tablet contains 80, 160, 160 mg valsartan respectively and 12,5, 12,5, 25 mg hydrochlorothiazide respectively. S3 A44/7.1.3/0018, 0019,
0020. NAM NS2 14/7.1.3/0061, 0062, 0063. ENAP 5, 10, 20 mg. Each tablet contains 5 mg enalapril maleate respectively. S3 A34/7.1.3/0085, 0086, 0087. NAM NS2 04/7.1.3/1138, 1137, 1136. FEDALOC 30 and 60 mg
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A45/7.1.3/0978, 0979. NAM NS2 17/7.1.3/0023, 0024. ZARTAN 50 and 100 mg. Each tablet contains 50, 100 mg losartan potassium respectively. S3 A41/7.1.3/0287, 0289. NAM NS2 08/7.1.3/0067, 0086. ZARTAN CO
50/12,5 and 100/25. Each tablet contains 50, 100 mg losartan potassium and 12,5, 25 mg hydrochlorothiazide respectively. S3 A42/7.1.3/1068, 1069. NAM NS2 12/7.1.3/0070, 0071. For full prescribing information, refer to
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MIMS HANDBOOK
OF GERIATRIC MEDICINE

Treatment Approaches

ii Prof Jaques R Snyman
MBChB M Pharm Med MD
Credits
Silke Friedrich
Editor-in-Chief
Lynette Strydom
Business Manager
Publishing Editor Dr Jaco Lotriet
CPD Compiler BPharm, PhD (Pharm)

Advertising Executives Barbara Milroy
Loren Chimes
Production Manager
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GM: Magazines Tanya Pretorius
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Jocelyne Bayer

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Copyright ©2017 MIMS [A division of Times Media (Pty) Ltd] ISBN: 978-0-9947184-0-2
This book is copyright. Apart from any fair dealing for the purposes of private study, research,
criticism or review as permitted under the Copyright Act, no part may be reproduced by any
process without written permission.

The opinions expressed in MIMS Handbook of Geriatric Medicine are those of the contributing
authors and do not necessarily reflect the opinion of the publisher.

MIMS [a division of Times Media (Pty) Ltd] is an independent company and is not affiliated to
any pharmaceutical manufacturer or professional association. The advertising carried in MIMS
Handbook of Geriatric Medicine is independent of and has no influence over the editorial content.

Although every effort has been made in compiling, editing and checking the information
given in this publication to ensure that it is accurate, the authors, the editors, the publisher and
its employees or agents shall not be responsible for the continued currency of the information,
or for any errors, omissions or inaccuracies in this publication, whether arising from negligence or
otherwise, or for any consequences arising therefrom. Readers should consult the Information for
Prescribers, as well as the manufacturers’ package inserts, for indications, dosages and/or other
relevant information.

HANDBOOK OF GERIATRIC MEDICINE

iii

Contents

Information for Prescribers viii...................................................................................................................................

TREATMENT APPROACHES

Cardiovascular conditions

Antihypertensives 1................................................................................................................................................................
Prof IG Okpechi
Cardiovascular risk in type 2 diabetes mellitus and
new treatment options 9.................................................................................................................................................
Dr A Kok
Common cardiac conditions in the elderly 14...............................................................................
Dr GE Letcher
Deep vein thrombosis 22...............................................................................................................................................
Dr D Reddy
Ischaemic heart disease – a sub-Saharan African perspective....................28
Prof M Ntsekhe, Dr K Lukhna
Risk of cardiovascular disease in women 36....................................................................................
Prof IG Okpechi
Acute myocardial infarction, unstable angina and stable angina.......... 44
Prof M Ntsekhe

Endocrine conditions

Initiating and titrating basal insulin treatment in patients
with type 2 diabetes 52....................................................................................................................................................
Dr M Koning
Erectile dysfunction in men over 65 55........................................................................................................
Dr E Rudolph, CN Boffard
Hormone therapy in peri- and postmenopausal women 61.......................................
Prof LC Snyman
Management of type 2 diabetes in the elderly 65....................................................................
Dr EF Delport

Neuropsychiatric conditions

Dementia and delirium 72.............................................................................................................................................
Ms K Mayimele, Prof B Chiliza
Diagnosis and management of generalised anxiety disorder
and panic disorder in adults 80............................................................................................................................
Drs AB Locke, N Kirst, CG Shultz

HANDBOOK OF GERIATRIC MEDICINE

iv

Clinical vignettes in geriatric depression 89.......................................................................................
Dr GD Spoelhof, Dr GL Davis, Dr A Licari
Normal and abnormal sleep in geriatric patients 100.........................................................
Dr AJ Bentley

Musculoskeletal conditions and pain

Osteoarthritis 107......................................................................................................................................................................
Prof AA Kalla
Osteoporosis 114........................................................................................................................................................................
Dr AJ de Weerd
Gait and balance disorders 118..........................................................................................................................
Dr J Smuts
Clinical pharmacology of corticosteroids: use in the elderly 123.......................
Prof JR Snyman
Chronic pain in the aged 127.................................................................................................................................
Dr S Chetty

Pulmonary conditions

Chronic obstructive pulmonary disease in the elderly 133...........................................
Prof DJV Weich
Acute lung infections in the elderly 140....................................................................................................
Prof DJV Weich
Influenza: prevention, treatment and vaccine indications 146..............................
Dr C Cohen

Dermatological and aesthetic conditions

Hair loss in the elderly 154...........................................................................................................................................
Dr CN Davies
Photo-ageing lesions including solar keratosis/actinic keratosis 159...........
Dr M Smit
Varicose veins 172.................................................................................................................................................................
Dr N le Grange

Visual impairment

Glaucoma 178.............................................................................................................................................................................
Prof D Meyer
Age-related macular degeneration 187................................................................................................
K Panesar

HANDBOOK OF GERIATRIC MEDICINE

KeenMindR

Calm focus, memory & cognitive function

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References: 1. Stough, et al. Psychopharmacology. 2001;156:481-484. 2. Roodenrys, et al. Neuropsychopharmacology. 2002;27:279-281. 3. Stough, et al. Phytotherapy Research. 2008;22:1629-1634. ® KeenMind is a registered trademark of Flordis Pty Ltd.

vi

Urinary system conditions
Benign prostatic hyperplasia 195.......................................................................................................................
Dr W Lambrechts
Incontinence in ageing individuals 198....................................................................................................
Dr W Lambrechts
Oncology screening and care
Cancer screening in the elderly patient – general guidelines.....................203
Dr D Eedes
Cancer screening in the elderly patient – specific guidelines.....................209
Dr D Eedes
General
The use of assistive devices 216...........................................................................................................................
Dr M de Villiers
SUBJECT INDEX 222..............................................................................................................................................................

HANDBOOK OF GERIATRIC MEDICINE



viii

Information for Prescribers

When prescribing any product mentioned n All entries have been compiled stric-
in MIMS Handbook of Geriatric Medicine, tly in accordance with the current
doctors should be mindful of the impor- package inserts in the publisher’s
possession.
tant points listed below.
n Hypersensitivity to the ingredient(s)/ n M o n o - a m i n e o x i d a s e i n h i b i t o r s
(MAOIs) have a prolonged action, so
components of any medicine contra- patients should not take any of the
indicates its use. foods or medicines known to cause
reactions for at least 14 days after
n Medicines should not be prescribed to stopping treatment.
pregnant or lactating women unless the
anticipated benefit clearly outweighs n Certain medicines (i.e. those that
any potential risk to the foetus. cause CNS depression) may lead to
drowsiness and impaired concentra-
n The possibility of drug accumulation tion, which may be aggravated by
should be considered in the pres- the simultaneous intake of alcohol or
depression agents.
ence of significant renal or hepatic
n All editorial has been compiled by
impairment. authorities in their respective field, and
opinions expressed are not necessarily
n Tolerance to medicines is likely to be those of the publisher, its employees,
agents or editors. Some indications
less with extremes of age. and/or dosages described in the
articles may therefore differ from the
n Side effects refer only to those which registered package insert of the rele-
vant product. MIMS does not promote
occur at the recommended dosages or take responsibility for the “off-label”
and correct route of administration. use of medicines, but allows for the
n Drug interferences with laboratory publication of new or evidence-based
tests and physical incompatibilities information. Health-care professionals
common with parenteral solutions are to use this information at their
have not been included. discretion, and are referred to current
n Dosages given are for adults only manufacturer product literature for
unless otherwise stated. For additional registered indications and dosages.
information on dosage directions,
particularly in the case of parenteral
products, consult the MIMS Desk
Reference where applicable, the
pharmaceutical company or the
current package insert.

HANDBOOK OF GERIATRIC MEDICINE

Risk of cardiovascular disease in women 1

Antihypertensives TREATMENT APPROACHES

Prof IG Okpechi proper measurement of blood pressure
MBBS, FWACP, PhD (UCT), Cert Nephrol (BP), the difficulty often lies with decid-
PhD(SA) Phys ing when to commence therapy
 Associate Professor and Director of and what agent(s) should be used for
Research, Division of Nephrology and treatment.
Hypertension and the Kidney and
Hypertension Research Unit, Department INDICATIONS FOR DRUG THERAPY:
of Medicine, University of Cape Town hypertension without compelling
indications for specific agents
Hypertension is an important public health
challenge of global proportions. It repre- Figure 1 provides a summary of the indica-
sents one of the most important modifiable tions for drug therapy in adult hypertensive
risk factors for preventing cardiovascular patients, according to the Southern
disease (CVD) and death. African hypertension guidelines. The indi-
cations for therapy are:
Drug treatment of the hypertensive n A ntihypertensive therapy should be
patient is in constant evolution in respon-
se to available new data and guidelines prescribed for average diastolic blood
published every year by researchers, pressure (DBP) of ≥100 mmHg or
pharmaceutical industries and various average systolic blood pressure (SBP)
experts in this field. As the diagnosis of of ≥160 mmHg in patients without
hypertension can be easily made by the macrovascular target organ damage
or other cardiovascular risk factors.

Figure 1. Southern African hypertension management flow diagram
based on added CVD risk

Stratify according to added risk BP level + major risk factors + TOD +
established CV/renal disease

Low added risk Moderate added risk High/very high added risk

Lifestyle modification as appropriate

Monitor BP and other risk Monitor BP and other risk
factors for 6 -12 months factors for 3-6 months

SBP ≥140 SBP <140 SBP <140 SBP ≥140
or DBP ≥90 or DBP ≥90
and DBP <90 and DBP <90

Continue to monitor

Begin drug
treatment

HANDBOOK OF GERIATRIC MEDICINE







































Common cardiac conditions in the elderly 21

n Anticoagulation reactive cellular hypertrophy. Circ Res. TREATMENT APPROACHES
– Usually mandated in the very 1991;68:1560-1568.
11. W ong LS, et al. Aging, telomeres and heart
elderly, but there may be contra- failure. Heart Fail Rev. 2010;15:479-486.
indications, in which case one 12. L akatta EG, Levy D. Arterial and cardiac
could consider a left atrial aging: major shareholders in cardiovas-
appendage closure device. cular disease enterprises: Part II: the aging
heart in health: links to heart disease.
Ventricular dysrhythmias Circulation. 2003;107:346-354.
n These are usually haemodynamically 13. Pandya K, et al. Fibrosis, not cell size, deline-
ates beta-myosin heavy chain re-expres-
important, and require urgent treat- sion during cardiac hypertrophy and
ment, or, if not available, referral. normal aging in vivo. Proc Natl Acad Sci
USA. 2006;103:16864-16869.
See Figure 2 for the Vaughan-Williams 14. C hen W, Frangogiannis NG. The role of
Classification of anti-arrhythmic drugs. inflammatory and fibrogenic pathways in
heart failure associated with ageing. Heart
REFERENCES Fail Rev. 2010;15:415-422.
1. Levy D, et al. Long-term trends in the inci- 15. U delson JE. Heart failure with preserved
ejection fraction. Circulation. 2011;124.
dence of and survival with heart failure. N 16. K omajda M, et al. Contemporary manage-
Engl J Med. 2002;347:1397-1402. ment of octogenarians hospitalized for
2. Bleumink GS, et al. Quantifying the heart heart failure in Europe: Euro Heart Failure
failure epidemic: prevalence, incidence Survey II. Eur Heart J. 2009;30:478-586.
rate, lifetime risk and prognosis of heart 17. Barsheshet A, et al. Predictors of long-term
failure. The Rotterdam Study. Eur Heart J. (4-year) mortality in elderly and young
2004;25:1614-1619. patients with acute heart failure. Eur J
3. Jugdutt BI. Prevention of heart failure in the Heart Fail. 2010;12:833-840.
elderly: when, where and how to begin? 18. M ogensen UM, et al. Clinical characteris-
Heart Fail Rev. 2012;17:531-544. tics and major comorbidities in heart failure
4. Roger VL, et al. Trends in heart failure inci- patients more than 85 years of age
dence and survival in a community-based compared with younger age groups. Eur J
population. JAMA. 2004;292:344-350. Heart Fail. 2011;13:1216-1223.
5. Goldberg RJ, et al. Trends in mortality 19. K elder JC, et al. The diagnostic value of
attributed to heart failure in Worcester, physical examination and additional
Massachusetts, 1992 to 2001. Am J Cardiol. testing in primary care patients with
2005;95:1324-1328. suspected heart failure. Circulation.
6. Fonarow GC. Epidemiology and risk stratifi- 2011;124:2865-2873.
cation in acute heart failure. Am Heart J. 20. B arsheshet A, et al. Applicability of a risk
2008;155:200-207. score for prediction of the long-term
7. Manzano L, et al. Predictors of clinical (8-year) benefit of the implantable cardio-
outcomes in elderly patients with heart verter-defibrillator. J Am Coll Cardiol. 2012;
failure. Eur J Heart Fail. 2011;13:528-536. 59:2075-2079.
8. Nieminen MS, et al. EuroHeart Failure 21. Inglis SC, et al. Structured telephone
Survey II (EHFS II): a survey on hospitalized support or telemonitoring programmes for
acute heart failure patients: description of patients with chronic heart failure.
population. Eur Heart J. 2006;27:2725-2736. Cochrane Database Syst Rev. 2010;8.
9. Forman DE, et al. Influence of age on the 22. A hmed A. DEFEAT – heart failure: a guide to
management of heart failure: findings from management of geriatric heart failure by
Get With the Guidelines-Heart Failure generalist physicians. Minerva Med. 2009
(GWTG-HF). Am Heart J. 2009;157:1010-1017. Feb;100(1):39-50.
10. O livetti G, et al. Cardiomyopathy of the 23. B rignole M, et al. Guidelines on manage-
aging human heart. Myocyte loss and ment (diagnosis and treatment) of
syncope. Eur Heart J. 2001;22:1256-306.

HANDBOOK OF GERIATRIC MEDICINE

22 CARDIOVASCULAR CONDITIONS

Deep vein thrombosis

Dr D Reddy induration that occurs in up to 40 % of
MBChB (UCT) FC Cardio (SA) cases after a DVT.
 Consultant Surgeon: Department of
Cardiothoracic Surgery, Inkosi Albert PATHOPHYSIOLOGY
Luthuli Central Hospital, Durban
Lower limb DVT is well known to most
Deep vein thrombosis (DVT) remains a patients, and has spurred the creation of
common yet often misdiagnosed clinical the term "economy class syndrome",
entity, with an annual incidence of which refers to the risk factor of prolonged
approximately 67 per 100 000 amongst the immobilisation, hypoxia and dehydration
general population. Between 1 % and 8 % experienced during long-haul flights.
of patients who develop pulmonary Virchow's triad remains the basis of the
embolism will die, whereas others will aetiological factors, namely endothelial
experience long-term complications such injury, stasis or turbulence of blood flow,
as post-thrombotic syndrome (40 %) and and hypercoagulability. These factors
chronic thrombo-embolic pulmonary may, in isolation or together, set in motion
hypertension (4 %).1 the coagulation cascade.

Whilst venous thrombo-embolism is Virtually all patients treated for venous
predominantly a disease of the elderly, thrombo-embolism have at least one risk
peaks in incidence occur in the younger factor. Untreated, the resultant thrombus
age group in the neonatal period, and the generally propagates and may embolise
disease is associated with pregnancy or to the pulmonary vasculature via the right
the use of oral contraceptives in adoles- side of the heart. Spontaneous thrombolysis
cent women. Following hip or knee surgery, and recanalisation of the vein then occurs
the incidence of DVT is estimated to be in the natural course of the disease, with
between 40 % to 60 %, and the risk of fatal D-dimers being a degradation product of
pulmonary embolism between 2 % to 7.5 % a cross-linked fibrin clot, and hence one of
without pharmacological prophylaxis.2 the biomarkers of this process. As
mentioned, a proportion of patients will
DVT classically involves the lower limbs, suffer from the long-term consequences of
with upper limb involvement uncommon post-thrombotic syndrome.
in the absence of an indwelling intrave-
nous catheter or an intrinsic thrombophilia. DIAGNOSIS
Lower limb DVT is classified as proximal
(thigh or popliteal veins) or distal (calf Traditionally, the diagnosis of DVT was
veins involved). While proximal segment reliant upon a suggestive history com-
DVTs are associated with as high as a 50 % bined with non-specific clinical features,
incidence of pulmonary embolism if such as swelling, pain, loss of function and
untreated, a positive "Homan" sign. Diagnostic clinical
signs are notoriously unreliable, particu-
DVTs confined to the calf are associated larly in the obese patient, or an individual
with a less than 1 % risk of pulmonary with an immobilised limb following pelvic
embolism and less than 20 % risk of prox- or orthopaedic surgery.
imal propagation3. Limb complications
such as venous gangrene, phlegmasia The current diagnostic approach
alba dolens and phlegmasia cerulea attempts to rationalise the economic
dolens may require intervention by a burden of unnecessary investigations,
vascular surgeon. Post-thrombotic whilst cognisant of the potential conse-
syndrome (or post-phlebitic syndrome) is a quences of a delayed or mixed diag-
chronic entity characterised by leg nosis, and the associated medico-legal
swelling, pain, venous ectasia, and skin implications.

HANDBOOK OF GERIATRIC MEDICINE

PRADAXA® is now
indicated for acute
treatment and
prevention of VTE*4

For patients with VTE
disease transitioning from heparin...

THE EVIDENCE
ADDS UP TO

PRADAXA®1

YOUR FORESIGHT.

THEIR FUTURE.

*Venous Thromboembolism
References: 1. Schulman S, Kearon C, Kakkar AK, et al. Dabigatran Versus Warfarin in
The Treatment of Acute in Venous Thromboembolism. N Engl J Med. 2009; 361: 2342-52.
2. Pradaxa Package Insert. Ingelheim Pharmaceuticals (Pty) Ltd.
S4 Pradaxa® 150 mg. Each capsule contains 150 mg of dabigatran etexilate base (as mesilate salt).
Reg. No. 45/8.2/0162. For full prescribing information refer to the package insert approved by the
medicines regulatory authority.
Applicant details:
Ingelheim Pharmaceuticals (Pty) Ltd, 407
Pine Ave, Randburg. Tel: +27 (011) 348 2400.
Cpy. Reg. No. 1966/008618/07.
BI Ref. No. GPM-PX-0022-ZA

24 CARDIOVASCULAR CONDITIONS

The clinician is directed to investigations Venous ultrasonography is non-invasive,
using a combination of diagnostic safe, accessible, relatively inexpensive
acumen, knowledge of pretest probability and is the investigation of choice in
scores, and by adopting an evidence- patients stratified as DVT-likely. Contrast
based approach to diagnosis and venography is rarely utilised as it is inva-
treatment. In the past, a liberal approach sive, painful, and is associated with
to imaging resulted in only 10-25 % of vessel-wall damage, radiation exposure
patients suspected of having a DVT actu- and contrast-induced renal dysfunction.
ally having ultrasonographic evidence of Impedance plethysmography and
DVT. Serial ultrasound imaging, except in magnetic resonance imaging (MRI) are of
the context of specific sub-groups (such little use in the clinical setting.
as pregnant women), has also proven
inefficient1. The fundamentals of the diagnostic
algorithm for DVT (see Figure 1) in current
A widely used clinical prediction model, clinical practice includes establishing the
the Wells score, takes into account the pretest probability of a DVT, combined
clinical features and risk factors for DVT, with the results of a D-dimer assay, and
categorising patients as having a low, finally (and usually unequivocally) imaging
medium or high probability of DVT2. This in the form of compression ultrasound with
model has been shown to be reproduc- Doppler2. Imaging further enables the
ible, and allows identification of patients operator to localise the extent of the
who do not require primary or serial ultra- disease, and is extremely useful in the
sonography (see Table 1). evaluation of a suspected recurrent DVT in
a previously afflicted limb.
D-dimer levels are elevated in acute
thrombo-embolism, as well as in patients PROPHYLAXIS
with a variety of nonthrombotic condi-
tions, such as recent major surgery, DVT prophylaxis may be mechanical or
pregnancy or trauma. The D-dimer assay is pharmacological. Mechanical methods
a useful test to exclude DVT in patients such as intermittent pneumatic compres-
with a low pretest probability of DVT, sion devices and graduated compression
particularly in the outpatient setting. stockings enhance blood flow in the deep

Table 1. Pretest probability assessment (Wells score)

Clinical feature Score*

Active cancer (treatment ongoing or within previous 6 months or palliative) 1

Paralysis, paresis, or recent plaster cast immobilisation of the lower 1
extremities

Recently bedridden for three days or major surgery within 12 weeks requiring 1
general or regional anaesthesia

Localised tenderness along the distribution of the deep veins 1

Entire leg swollen 1

Calf swelling 3 cm >asymptomatic side (measured 10 cm below tibial 1
tuberosity)

Pitting oedema limited to the symptomatic leg 1

Collateral superficial veins (nonvaricose) 1

Alternative diagnosis as likely as or more likely than DVT -2

* Interpretation: 0 = low probability 3 % frequency of DVT
1-2 = medium probability 17 % frequency of DVT
>3 = high probability 75 % frequency of DVT

HANDBOOK OF GERIATRIC MEDICINE

Deep vein thrombosis 25

Figure 1. Algorithm for diagnosing DVT using clinical assessment, D-dimer testing, TREATMENT APPROACHES
and venous ultrasonography

Clinical features and risk factors (DVT)

Clinical probability

DVT unlikely DVT likely
(probability score ≤1) (probability score >1)

D-dimer assay Venous USS

Negative Positive Positive Negative

DVT Venous USS Diagnose/ D-dimer assay
excluded treat DVT

Negative Positive

Positive Negative DVT DVT follow-up
excluded studies
Diagnose/ DVT (repeat venous
treat DVT excluded USS in a week
or venography

veins of the leg, preventing venous stasis Fondaparinux, an indirect selective inhib-
and thrombosis. The risk of venous thrombo- itor of factor Xa, requires once-daily
embolism and post-thrombotic syndrome dosing and has a predictable response
are reduced by 50 % with the use of gradu- that does not require monitoring of
ated compression stockings following prothrombin times or partial thrombo-
proximal DVT2. Pharmacological prophy- plastin time. Dabigatran, an oral univalent
laxis consists of unfractionated heparin direct thrombin inhibitor, and rivaroxaban,
(UH), low molecular weight heparin a once-daily potent and selective oral
(LMWH), fondaparinux, oral direct selective factor Xa inhibitor, require no laboratory
thrombin inhibitors and factor Xa inhibitors. monitoring due to the predictable antico-
agulant effect. Rivaroxaban, a new oral
The benefits of LMW heparin over unfrac- direct factor Xa inhibitor, started six to
tionated heparin include2: eight hours after total hip and knee joint
n G reater bioavailability replacement surgery, was more effective
n Predictability and dose-dependent than enoxaparin started the previous
evening in preventing symptomatic
plasma level venous thrombo-embolism and all-cause
n Less risk of bleeding mortality, without increasing major
n L ower incidence of heparin-induced bleeding4. Aspirin as monotherapy is
generally not recommended for thrombo-
thrombocytopenia prophylaxis for any patient group. The
n L ower risk of heparin-induced duration of thromboprophylaxis varies
between 10 to 35 days in patients at high
osteoporosis risk for venous thrombo-embolism (VTE)
n No need for laboratory monitoring such as following hip or knee surgery, and
n C an be safely administered in is generally continued until discharge in
patients with an acute medical illness.
outpatient setting
n Duration of anticoagulant effect is HANDBOOK OF GERIATRIC MEDICINE

longer, permitting once- or twice-daily
administration

26 CARDIOVASCULAR CONDITIONS

TREATMENT therapy. Whilst warfarin remains the drug of
choice in long-term anticoagulation
The goal of DVT treatment is to prevent following DVT, LMWH is preferred in preg-
the extension of thrombus and pulmonary nancy due to the risks of teratogenicity and
embolism in the short term, and to prevent foetal haemorrhage. In patients with cancer,
recurrent thrombotic events and late LMWH may also be preferred due to the
complications (pulmonary hypertension improved efficacy in preventing venous
and post-thrombotic syndrome) in the thrombosis without increasing bleeding risk,
long term3. Initial treatment comprises as well as ease of management during inva-
heparin (unfractionated or low molecular sive procedures such as biopsies and
weight) to achieve a critical therapeutic indwelling central line placement.
ratio within the first 24 hours of treatment –
an activated partial thromboplastin time The standard intensity of oral anticoagu-
(aPTT) of 1.5 times the control value. Low lation therapy is an international norma-
molecular weight (LMW) heparin enables lised ratio (INR) of 2.0 to 3.0, which
home treatment, which results in an prevents recurrent thromboses and
improved quality of life for patients and decreases the risk of post-thrombotic
cost savings for the health-care system. syndrome. Low-intensity therapy (main-
Inpatient management may, however, be taining an INR of 1.5-1.9) is ineffective in
required for associated comorbidities, preventing recurrent DVT, and is not asso-
patients at risk of bleeding, and extensive ciated with a reduction in the risk of
DVT with local complications, such as bleeding. The duration of anticoagulation
phlegmasia cerulea dolens that requires remains a constant area of interest, with
parenteral pain control. LMW heparin has current guidelines based upon the risk of
a more predictable anticoagulant effect, recurrent DVT (see Table 2).3
thus avoiding the need to assess pro-
thrombin times, and is associated with a The newer generation of oral antico-
lower risk of heparin-associated throm- agulants that do not require monitoring,
bocytopaenia. such as dabigatran and rivaroxaban,
may also be suitable options for long-
Warfarin therapy should be com- term anticoagulation. Oral rivaroxaban,
menced on day one, and heparin at a dose of 15 mg twice daily for the first
(unfractionated or LMW) discontinued three weeks, followed by 20 mg once
after four to five days when the INR is daily thereafter, without the need for
greater than 2.0 for two consecutive days. laboratory monitoring, was as effective
Monotherapy with warfarin ab initio is and safe as standard therapy and may
insufficient due to the early prothrombotic provide a single-drug approach to the
tendency following warfarin introduction, initial and continued treatment of venous
and heparin must be used to initiate thrombosis.5

Table 2. Recommendations for the duration of anticoagulation for DVT

Episode of DVT Cause Duration
First 3-6 months
Reversible or time-limited risk factors –
First surgery, trauma, short-term immobility, 3-6 months
First oestrogen replacement At least 6 months
First 12 months to lifetime
Heterozygous thrombophilias
Recurrence Lifetime
Idiopathic

Malignancy (until resolved),
antiphospholipid antibody, combined or
homozygous genetic defects

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