Case 93 – update 2

We discussed what anticoagulant to start in our patient with a newly diagnosed DVT. There are a number of options and the main ones will include:

  • LMWH then warfarin
  • LWMH then dabigatran
  • Rivaroxaban
  • Apixaban
  • LMWH then edoxaban

 

Various factors need to be considered and the final approach needs to be individualised to the patient after discussion with them. Factors that may need to be taken into account include:

  • Presence of active cancer – LMWH generally better option if undergoing chemotherapy. DOACs are increasingly used in patients with malignancy.
  • Need for reversal agent – currently warfarin and dabigatran have reversal agents but anti-Xa reversal agent Andexanet alfa has been approved by FDA for reversal of rivaroxaban and apixaban)
  • Preferring oral vs parenteral
  • Extremes of body weight – DOACS generally advised against over 120kg
  • Ability to absorb – if absorption issues then parenteral anticoagulant or an anticoagulant that can be monitored reliably may be preferred
  • Ability to monitor – warfarin and LMWH are easily monitored. DOAC levels can be checked but interpretation is not always straightforward and titration of dose is not generally possible
  • Interacting medications
  • Preference to take once daily – warfarin, LMWH and rivaroxaban are all once daily
  • History or at risk of heavy menstrual bleeding – rivaroxaban has been associated with higher risk in non-randomised comparative studies
  • Not wanting to take any injections – rivaroxaban and apixaban do not require any period of LMWH
  • Ease of monitoring and facilities to do so (community vs hospital visits etc.)
  • Presence of antiphospholipid syndrome – currently warfarin and LWMH are the preferred option here
  • Local policies – this may dictate prescribing
  • Cost – this may dictate prescribing
  • Presence of renal failure – in the presence of severe renal failure warfarin is the best option for treatment of VTE although apixaban has been used for AF in dialysis-dependant patients. All other DOACs have limits and dose reductions depending on the degree of renal failure.
  • Presence of liver disease and coagulopathy – LMWH may be the best option here
  • Current or potential pregnancy – DOACs and warfarin are contraindicated in pregnancy but generally most are happy to become pregnant whilst on warfarin but to change to LMWH as soon as possible
  • History of gastritis and GI bleed – dabigatran has more GI side effects and rivaroxaban has possibly more GI bleeding.
  • Presence of coronary artery disease – dabigatran may have more cardiac side effects

 

Our patient prefers an oral option and would like a tablet to take once a day as he would find it easier to remember. He starts on rivaroxaban 15mg BD with a plan to drop to 20mg od after three weeks. He notices an improvement in his symptoms. He is asymptomatic and has no signs or symptoms of malignancy or autoimmune disease. He has a chest X-ray which is normal. Urinalysis is unremarkable and FBC, U&E, LFT and calcium are all within the reference range.

 

Two months later he attends again with extensive left leg swelling after having an initial improvement.

Questions

  • How do you counsel patients about to start anticoagulation? Any dos and don’ts?
  • Do you offer compression hosiery routinely?
  • His leg is worse again – how do you proceed?

 

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