Comparison of Direct Oral Anticoagulants and Warfarin in the Treatment of Deep Venous Thrombosis in the Chronic Phase

Abstract

SummaryWe assessed the efficacy and safety of direct oral anticoagulants (DOACs) for the treatment of deep venous thrombosis (DVT) in the chronic phase through comparison with conventional warfarin therapy.A total of 807 consecutive patients who were diagnosed with having DVT in the chronic phase were included (484 patients to warfarin therapy and 323 patients to DOAC therapy). The condition of leg veins was assessed 3 to 6 months after starting the therapies by ultrasound examination. Major bleeding and mortality during the therapies were followed-up.There was no significant difference between the two groups in the thrombosis improvement rate (DOAC group: 91.2% versus warfarin group: 88.9%). There was no significant difference between the two groups in major bleeding (DOAC group: 1.8% versus warfarin group: 1.8%). In patients with active cancer, the DOAC group had a borderline higher thrombosis improvement rate than the warfarin group (92.1% versus 80.0%, P = 0.05). The proportion of major bleeding in the patients with active cancer was slightly higher in the warfarin group than in the DOAC group (4.3% versus 2.8%; P = 0.71). Active cancer was not an independent risk factor for major bleeding and recurrence in the DOAC group (OR 2.68, 95% CI 0.51-14.1; P = 0.24 and OR 0.65, 95% CI 0.20-2.07; P = 0.47).In treatment using oral anticoagulants for DVT in the chronic phase, DOACs exhibited equal efficacy and safety as warfarin did. Particularly DOACs appear to be an attractive therapeutic option for cancer-associated DVT in chronic phase, with relatively low anticipated rates of recurrence and major bleeding.(Int Heart J 2018; 59: 126-135) Key words: Thrombosis dissolution, Cancer T he number of cases of deep vein thrombosis (DVT) is increasing in Japan, as well as other countries, because of the aging population, westernized diets, and advanced diagnostic technology.1,2) For the treatment of DVT, warfarin therapy was highly effective.3,4) However, warfarin administration in the chronic phase has many disadvantages, such as food and drug interactions, varying responses among individuals, regular monitoring of the international normalized ratio (INR), and maintaining the INR within the therapeutic range of 1.5-2.5.5,6) Thus, warfarin therapy for DVT in the chronic phase is a burden for patients and is very costly.Recently, direct oral anticoagulants (DOACs) have been developed because they require no monitoring and have few drug and food interactions. DOACs have been shown to be effective in phase 3 randomized trials for acute and long-term treatment of DVT. [7][8][9][10][11][12][13][14] However, the qualitative evaluation of the effect and the data of the safety evaluation in the chronic phase in routine clinical practice are not sufficient.Patients with active cancer are prone to developing and having recurrent DVT. Low-molecular weight heparin (LMWH) has been more effective and safer than vitamin K antagonists in patients with cancer-related DVT. [15][16][17][18] Current guidelines recommend a 6-month course of LM...

Patient Satisfaction with Direct Oral Anticoagulants and Warfarin

“…This outcome is reasonable because dosing and administration of DOACs are simple, there is no need for INR monitoring or drug/food restrictions, and risk of fatal bleeding, in comparison with that associated with traditional VKAs, is reduced. 12) We did note, however, that only 34.5%-40% of the patients were highly satisfied with anticoagulant therapy for benefits, and the ACTS benefits scores were somewhat lower among the DOAC users than among the warfarin users. Two large randomized trials (EINSTEIN-DVT/PE studies)…”

Construction and Validation of a Nomogram for Predicting the Risk of Deep Vein Thrombosis in Hepatocellular Carcinoma Patients After Laparoscopic Hepatectomy: A Retrospective Study

“…DVT disappeared within 1 month in 57 (86.4%) cases, with chronic DVT remaining in 9 (13.6%) cases, including 3 unilateral distal, 5 bilateral distal and 1 unilateral proximal DVT case. 27 In another 6 (9.1%) cases, the DVT disappeared in the next two months, while 2 (3.0%) unilateral distal DVT patients and 1 (1.5%) bilateral distal DVT patient still had the thrombus after 3 months (Table 3). No PE or major bleeding occurred during the treatment.…”

Compared to randomized studies, observational studies may overestimate the effectiveness of DOACs: a metaepidemiological approach

“…Three studies [20][21][22] were excluded because they evaluated the same patients as two other larger studies [23,24], and more than half of their enrollment periods overlapped with those of the other studies. Finally, 26 studies (totalling 276,092 patients) were included : 6 RCTs [25-30], 4 prospective cohort studies [31][32][33][34], 12 studies using living databases (2 using living clinical databases [35][36] and 10 using living health administrative databases [18,23,24,[37][38][39][40][41][42][43]), and 4 retrospective cohort studies [44][45][46][47].…”