Dual Anticoagulation in Recurrent Thromboembolic Events with Failure of Monotherapy: A Novel Approach

Abstract

In the last few decades many new anticoagulants (i.e direct thrombin and factor ten inhibitors) have been introduced with efficacy that rivals older drugs in the treatment of venous thromboembolism (VTE). However, for all their success, management of patients with recurrent thromboembolic events is still a challenging clinical scenario and not well addressed in the literature. We report the case of a young female with recurrent thromboembolisms in spite of using both newer agents and more conventional therapies. Ultimately, she is started on dual anticoagulation with warfarin and rivaroxaban without recurrence. This case report demonstrates that dual anticoagulants can be utilized in patients with recurrent VTE who fail single agent therapy. It also underscores the need for studies further elaborating on the utility of dual anticoagulants as a treatment modality for patients failing monotherapy.

Dual anticoagulation with fondaparinux and dabigatran for treatment of cancer‐associated hypercoagulability

“…Both were successful, describing dalteparin plus warfarin for multiple recurrences of cancer-associated VTE 9 and rivaroxaban plus warfarin for multiple recurrences of idiopathic VTE. 10 Our patient appears to have had a more severe thrombotic course than either of these previously described cases.…”

An Atypical presentation of pulmonary embolism in a critically ill patient

“…Clinical suspicion of a PE was also low due to our patient being on prophylactic anticoagulation. However, patients may still develop PEs despite being anticoagulated, termed anticoagulation failure, and further hematological work up is indicated in these patients [7] .…”

Dual Anticoagulation With Warfarin and Apixaban: A Case Report

“…However, per the literature review, there are several case reports on other DOACs used with warfarin. One case report demonstrated the efficacy of rivaroxaban 15 mg twice daily in combination with warfarin with a therapeutic goal INR range of 2-3 in a patient with no known thrombophilias [3]. Two other case reports presented patients with diagnoses of cancer successfully managed on dual anticoagulation with dalteparin in combination with warfarin with a therapeutic goal INR range of 2-3 [4].…”

“…In most cases, a single anticoagulant is sufficient to prevent VTEs [2]. However, in rare instances, it is not [3,4]. We present a case of a young female with an extensive VTE history who required dual anticoagulation therapy to prevent clot recurrence.…”