Management of suspected and confirmed recurrent venous thrombosis while on anticoagulant therapy. What next?

Abstract

Suspected recurrent venous thromboembolism (VTE) is a common and vexing clinical problem. Confounding the diagnosis of recurrent VTE is a high frequency of residual VTE from prior VTE. The diagnosis of recurrent VTE must be established by comparing current imaging with past imaging to distinguish acute from chronic thrombosis. Next, we must ascertain if non-compliance was the cause of "apparent therapeutic failure" and if non-compliance is at play then re-initiate anticoagulant therapy. Therapeutic failure is relatively uncommon. As such, we must consider underlying causes of therapeutic failures including malignancy and potent thrombophilias. Finally, short term anticoagulant management of therapeutic failures is controversial, and requires further research, but the best current evidence supports a course of full-dose low-molecular-weight heparin (LMWH) (and dose escalated LMWH if failure occurs while on full-dose LMWH). 2.1. How frequent is residual venous disease? Cohort studies with serial imaging of deep vein thrombosis (DVT) and/or pulmonary embolism (PE) demonstrate how often residual venous disease will persist on imaging. In the REVERSE study, 646 patients with unprovoked VTE had "baseline" leg vein imaging and/or ventilation/perfusion scan (V/Q) 5-7 months after index DVT and/or PE [1]. Baseline imaging was abnormal in 60.5% (391/646) of patients.

Long‐term risk of recurrent venous thromboembolism among patients receiving extended oral anticoagulant therapy for first unprovoked venous thromboembolism: A systematic review and meta‐analysis

“…This information has important implications for clinical practice. Firstly, the diagnosis and management of recurrent VTE in patients receiving anticoagulation therapy remain difficult 50,51 . Suspected recurrent VTE is common 52 but given the high efficacy established for oral anticoagulants in the secondary prevention of VTE, clinicians and patients assume that anticoagulant therapy offers near‐total protection against recurrent VTE.…”

Use of direct oral anticoagulants in ICU patients. Part II – Clinical evidence

“…Patients on DOAcs can have a recurrent vte [33,34]. in such cases, an incorrect dose of DOAc, noncompliance, and any drug interactions should be excluded.…”

“…in such cases, an incorrect dose of DOAc, noncompliance, and any drug interactions should be excluded. such cases can be managed by switching to full-dose lMWH for at least 1 month [34,35].…”

Developing Deep Venous Thrombosis while on Rivaroxaban: A Review of Rivaroxaban

“…Unlike warfarin, which could be controlled by regular INR measurements, under coagulation in DOACs would be challenging to confirm even if the patient has taken the medication because of tests such as an anti-Xa measurement for (rivaroxaban, apixaban or edoxaban) are not widely used. Also, there are neither validated tests nor expected therapeutic ranges for these tests [27]. The consequences of non-adherence in the case of DOAC, even if missing a single dose, can result in more significant consequences than VKA because of the relatively short half-lives, as demonstrated in the introduction (Figure 1).…”

“…The consequences of non-adherence in the case of DOAC, even if missing a single dose, can result in more significant consequences than VKA because of the relatively short half-lives, as demonstrated in the introduction (Figure 1). Therefore compliance is very critical to provide protection from stroke and VTE [27,28].…”