Introduction
If you are diagnosed with a blood clot in your leg or pelvis, known as deep-vein thrombosis (DVT), your doctor is likely to prescribe anticoagulants, which prevent new blood clots from forming and existing clots from growing. Your body will naturally break nearly all clots down over time. Among the most frequently used anticoagulants today are warfarin (blood-thinner pills) and two types of heparin, called unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH). Traditionally, you would stay in hospital for 5 to 7 days during treatment with either UFH or LMWH, while also taking blood-thinner pills. If your case is not complicated, your doctor may let you go home earlier, after training you to inject yourself with LMWH (it is also possible to have a friend or relative trained to inject you). During home treatment, your treatment will change to blood-thinner pills alone, with blood tests and dosage adjustments, which you will continue to take for at least 3 months. When possible, you will not be bedridden and you may try to move around as much as you did before you had a blood clot.

UFH must be given in the hospital, as it is administered as a continuous drip into your vein, and you must undergo frequent blood tests to monitor and correct the dose. Staying in the hospital is not only expensive, but is also inconvenient to many patients.

In contrast to UFH, LMWH is injected under your skin in a fixed dose based upon your weight. No frequent blood tests to monitor how easily your blood clots are necessary. Therefore LMWH is a more convenient treatment for you and your doctors and nurses. It is so convenient, in fact, that it is increasingly being used to treat patients at home. Home treatment with LMWH has been shown to be safe, effective, practical, and cost-effective.

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Can I be treated at home?
Before you can be considered for home treatment with LMWH, your hospital doctor will need to:

• identify any medical reasons – such as other illnesses or an extensive (large) clot – that would require in-hospital treatment
• determine whether you have enough support to let you care for yourself at home
• discuss your and primary care doctor’s preferences for the treatment of DVT at home or in hospital. If your primary care doctor cannot be contacted, you will probably be admitted to hospital for treatment.

If you have no other medical conditions that need in-hospital treatment, if you have a friend or relative who can help take care of you at home, and if your own primary care doctor supports home treatment for DVT, then you are probably eligible for home treatment.

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Is home treatment as effective and safe as in-hospital treatment?
Findings from 8 studies involving thousands of patients show that home treatment with LMWH is just as effective as in-hospital treatment with UFH in preventing the development of new blood clots. Patients treated at home with LMWH are not more likely than those treated in hospital with UFH to experience side effects such as bleeding. The obvious benefit of the treatment of DVT at home is a reduction in the length of hospital stay. Home treatment with LMWH is as effective as hospital treatment with LMWH, but is much less expensive.

Most individuals can be treated at home: a community nurse can easily teach you or someone you trust how to inject the LMWH. More than 6 out of 10 people treated for DVT will be eligible and able to take LMWH at home.

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Do I need treatment in hospital?
The need to be admitted to hospital depends mainly on factors related to infrastructure rather than medical reasons, as shown in one study in which fewer than 3 in every 100 patients were admitted for medical reasons such as severe pain or the presence of a simultaneous problem. There are several other reasons that may prevent you from being treated at home: 

• your hospital doctor or your own primary care doctor may have concerns about bleeding or may disagree for another medical reason with you being treated at home
• it may prove difficult for you to manage LMWH injections by yourself at home
• you may have no one to help you with injections
• your treatment with blood-thinner pills cannot be monitored as an outpatient in the early phase.

Of the people with DVT who require in-hospital treatment, more than 9 out of 10 are hospitalized because of other illnesses, (such as a blood clot in their lung [a pulmonary embolism] that requires treatment with oxygen, cancer, or because they have recently undergone surgery). Cancer is probably the most frequently encountered disease that patients with DVT suffer from in addition to their clotting problems. Between 10 and 20 of every 100 patients diagnosed with a blood clot have previously been diagnosed with cancer. This does not mean that being diagnosed with a blood clot increases your risk of developing cancer, but rather that patients with cancer are more likely to develop a blood clot. However, even if you have both DVT and cancer, you may still be eligible for home treatment of your blood clot, which can be safe and effective and significantly improve your quality of life.

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Information for patients treated at home
In conclusion, for home treatment of DVT to be effective, your hospital doctor must:

• first identify whether you are eligible
• discuss the possibility with your own primary care doctor
• provide step-by-step instructions for both you and your primary care doctor
• provide all of the supplies needed to treat yourself
• provide ready access to a community nurse for assistance with injections, when required.

The information available to you will depend on where you live, but you should be able to find out more about home treatment for DVT through your own primary care doctor or hospital doctor.

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References
Ageno W et al. Selecting patients for home treatment of deep vein thrombosis: the problem of cancer. Haematologica 2002;volume 87:pages 286–91.

Geerts WH et al. Prevention of venous thromboembolism. Chest 2001;volume 119 Suppl 1:pages 132S–75S.

Chong BH, on behalf of the ASTH DVT Study Group. A randomized, prospective, multicentre study comparing the efficacy, safety and cost of once-daily enoxaparin given at home with unfractionated heparin given in hospital in the treatment of deep-vein thrombosis. Blood 2002;volume 100:abstract 2272.

Koopman MW 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. New England Journal of Medicine 1996;volume 334:pages 682–7.

Lapidus L et al. Home treatment of deep vein thrombosis. An out-patient treatment model with once-daily injection of low-molecular-weight heparin (tinzaparin) in 555 patients. Pathophysiology Haemostasis and Thrombosis 2002;volume 32:pages 59–66.

Levine M 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. New England Journal of Medicine 1996;volume 334:pages 677–81.

Schwarz T et al. Eligibility for home treatment of deep vein thrombosis: a prospective study in 202 consecutive patients. Journal of Vascular Surgery 2001;volume 34:pages 1065–70.

Segal JB et al. Outpatient therapy with low molecular weight heparin for the treatment of venous thromboembolism: a review of efficacy, safety, and costs. American Journal of Medicine 2003;volume 115:pages 298–308.

Wells PS et al. Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low-molecular-weight heparin: a comparison of patient self-injection with homecare injection. Archives of Internal Medicine 1998;volume 158:pages 1809–12.

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