BC Guidelines

Venous Thromboembolism – Diagnosis and Management (2024) provides recommendations for the diagnosis and management of venous thromboembolism (VTE) in adults aged ≥ 19 years with hemodynamic stability. It includes lower limb deep vein thrombosis (DVT) and pulmonary embolism (PE) diagnosis in the outpatient setting and management of acute VTE.

Superficial thrombophlebitis and thrombosis in unusual sites (e.g., cerebral venous thrombosis, splanchnic vein thrombosis, upper extremity thrombosis) are outside the scope of this guideline. For information refer to the Thrombosis Canada Guidelines.

Key Recommendations include:

When DVT/PE is suspected, first calculate the Wells Score to determine the likelihood of DVT/PE as “likely” or “unlikely” before ordering any testing.

• For outpatients with suspected DVT/PE:

  • Do not order D-dimer if DVT/PE is deemed “likely” per Wells Score. Proceed directly to imaging.

  • Order D-dimer when deemed ‘unlikely’ per Wells Score because a negative test indicates imaging is not necessary and DVT/PE is excluded.

• For inpatients, proceed directly to imaging because risk stratification using D-dimer has not been validated.

• While awaiting objective imaging to diagnose VTE, start empiric anticoagulant therapy in Patients with higher likelihood (“likely”) of DVT/PE.

• Most patients with hemodynamically stable VTE can be treated on an outpatient basis.

• Direct Oral Anticoagulants (DOACs) are considered as first line therapies for most outpatients. They are contraindicated in pregnancy, breastfeeding, liver failure (Child-Pugh class C), dialysis, or triple-positive antiphospholipid syndrome (i.e., has lupus anticoagulant, anticardiolipin and antibeta-2-glycoprotein-1 antibodies).

• Ensure appropriate anticoagulant dosage is used for the specific treatment phase (initial therapy, primary treatment, secondary prevention).

• Minimum duration of anticoagulation is 3-6 months for all patients with an acute DVT/PE.

• Referral to a thrombosis specialist is recommended to help determine optimal duration of anticoagulation. Continue anticoagulation therapy while awaiting referral.

• Avoid elective surgeries during the first 3-6 months of treatment.

• Hereditary thrombophilia testing and occult cancer screening are not indicated in most patients with thrombosis because results rarely influence management.

Chronic Obstructive Pulmonary Disease (COPD): Diagnosis and Management in Primary Care (2024) provides recommendations for adults with chronic obstructive pulmonary disease (COPD) in primary care.

Key Recommendations include:

Diagnosis

• Confirm all presumptive, symptom-based diagnoses of COPD one time with spirometry postbronchodilator ratio of FEV1/FVC < 0.7.
• Understand asthma and COPD are distinct diagnoses and may exist in the same patient. [NEW, 2024]
• CT is not needed to diagnose COPD but may be useful for screening lung cancer. [NEW, 2024]

Management

• Encourage all patients who smoke to quit or decrease use as treatment for COPD.
• Manage COPD early in order to slow disease progression. [NEW, 2024]
• Investigate and manage possible comorbidities to optimize outcomes.
• Refer patients, especially those with moderate to severe COPD, to a respiratory therapist for education and/or pulmonary rehabilitation.
• Provide appropriate immunizations to reduce the risk of exacerbation and mortality. [NEW, 2024]
• Consider checking baseline blood eosinophil count prior to commencing inhaled corticosteroid (ICS). [NEW, 2024]

Environmental Impact and Climate Change

• Consider medication options with lower environmental impact. Metered-dose inhalers (MDIs) contribute disproportionately to climate change, which in turn can affect COPD. [NEW, 2024]
• Prepare for climate events such as wildfire and extreme heat, which can exacerbate COPD symptoms. [NEW, 2024]

Education

• Prescribe appropriate controller and rescue medications along with a COPD action plan.
• Evaluate the patient's inhaler adherence and technique regularly.