NICE NG158 (2023 update): VTE diagnosis, management and thrombophilia testing

Official guidelineVenous thromboembolic diseases: diagnosis, management and thrombophilia testing (NG158). NICE, 2023.
Read the official guideline · Checked for a newer edition on 2026-10-20
We do not reproduce the guideline text — this page is an independent summary.

Who it applies to

Adults presenting with suspected or confirmed DVT or PE in primary, secondary or emergency care settings, including some guidance for special groups such as those with renal impairment or cancer; pregnant women are excluded, as VTE in pregnancy is covered separately by RCOG guidance.

Key recommendations

Use a two-level Wells score to estimate clinical probability of DVT or PE before further testing.
In patients with likely DVT, offer proximal leg vein ultrasound; if not available within 4 hours, give interim anticoagulation and perform D-dimer testing.
In patients with low clinical probability of DVT or PE, use D-dimer testing to help rule out the diagnosis before imaging.
For suspected PE with high clinical probability or a positive D-dimer, arrange CT pulmonary angiography as the main imaging test.
Offer a DOAC (apixaban or rivaroxaban) as first-line anticoagulation for most people with confirmed DVT or PE, without needing initial parenteral anticoagulation for these agents.
Where dabigatran or edoxaban is used, give initial low molecular weight heparin (LMWH) before starting the oral agent.
In people with active cancer and confirmed DVT or PE, offer a DOAC (apixaban, edoxaban or rivaroxaban) as the first-line treatment, taking into account interactions, bleeding risk and tumour type (e.g. gastrointestinal).
Continue anticoagulation for at least 3 months in all patients with confirmed proximal DVT or PE, then reassess whether to continue based on provoking factors and bleeding risk.
Consider extended anticoagulation beyond 3 months for unprovoked VTE after discussing bleeding risk and patient preference.
Do not routinely offer thrombophilia testing to patients who are continuing anticoagulation treatment.
Consider testing for antiphospholipid antibodies in patients with unprovoked DVT or PE if it is planned to stop anticoagulation.
Consider testing for hereditary thrombophilia in patients with unprovoked DVT or PE and a first-degree relative with VTE if it is planned to stop anticoagulation and this would change management.

What is new in this edition

The 2023 update strengthened guidance on cancer-associated VTE, moving DOACs from an alternative option to the recommended first-line treatment over LMWH.
Continued emphasis on DOACs as first-line treatment generally, consistent with the direction set in the 2020 update of this guideline.
Refinement of advice on thrombophilia testing to limit testing to situations where results would change management decisions.

Practice points for students

Remember the sequence for suspected DVT: Wells score first, then ultrasound or D-dimer depending on probability, not the reverse.
DOACs like apixaban and rivaroxaban can be started directly without heparin lead-in, unlike dabigatran and edoxaban.
Cancer-associated VTE is now managed with a DOAC first-line rather than LMWH as the default, reflecting the 2023 update.
Thrombophilia testing is not for everyone on anticoagulation; it mainly matters when a decision to stop treatment is being considered.
Unprovoked VTE raises the question of extended anticoagulation and should prompt a shared decision-making conversation about recurrence versus bleeding risk.

Condition

Pulmonary embolism