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Extended Treatment for VTE: Tailoring Treatment for Patients Who Need it

Patient case: Continued protection for patients

 
2020_1_22_TA_VTE_Extended_treatment_tailoring_newsletter
  • Cameron, aged 42 years, is a former smoker who maintains an active lifestyle. He recently presented with another deep vein thrombosis (DVT) and was admitted to hospital
  • He had a DVT 3 years ago and was treated with a vitamin K antagonist for 6 months, after which he discontinued therapy, and he was advised to stop smoking
  • Cameron’s preference is to be treated with a once-daily regimen that avoids injections. His doctor was confident in prescribing rivaroxaban given the evidence available for effective clot resolution within 21 days
  • He received rivaroxaban for 6 months and is now at clinical equipoise for continued anticoagulation

 

What might you consider in your decision whether to extend Cameron’s anticoagulation?

Why might Cameron be considered for extended anticoagulation?

Every patient is different, and extended treatment should be considered based on an individual’s risk factors and characteristics.

 

Cameron’s recent DVT was not attributed to a major transient risk factor such as surgery, so based on guidelines the decision to continue anticoagulation up to 6 months was clear.1,2

 

But, the decision to extend anticoagulation beyond 6 months, however, is tailored to the individual, balancing their risk of venous thromboembolism (VTE) recurrence against their risk of bleeding, whilst taking into account patient preference.1,2

 

So, what is Cameron’s risk of recurrence?

 

Cameron has already had a recurrent DVT. Although he stopped smoking after his first DVT, his other risk factors for recurrence include his family history of VTE and long coach journeys as part of his work. Patients with minor persistent or minor transient risk factors such as these, have a risk of recurrence as high as patients without recognised risk factors.3,4

2020_1_22_TA_VTE_Extended_treatment_tailoring_newsletter

Risk of VTE recurrence is high in patients who stop anticoagulation regardless of the underlying cause3

These factors all suggest that Cameron may benefit from the extended protection that continued anticoagulation would provide. However, Cameron may be wondering if the benefits of extended anticoagulation outweigh the risks.

What is the evidence for extended anticoagulation?

 

Several phase III studies of non-vitamin K antagonist oral anticoagulants (NOACs), rivaroxaban, apixaban, dabigatran and edoxaban, have confirmed the efficacy and safety of extended anticoagulation compared with placebo in reducing the risk of VTE recurrence in patients who were at clinical equipoise for continued therapy. Further information on these Phase III NOAC studies can be found here.

 

Reassuring results on the efficacy and safety of extended anticoagulation from patients treated in clinical practice has also been shown in real-world studies. Further information on relevant real-world studies can be found here.

 

Rivaroxaban is currently the only NOAC that allows the choice of two doses for extended treatment. For patients like Cameron who are at a reduced risk of recurrence, then the availability of a lower dose, rivaroxaban 10 mg once daily, still offers him protection from VTE recurrence, whilst maintaining a low risk of bleeding.4,5

2020_1_22_TA_VTE_Extended_treatment_tailoring_newsletter

 

EINSTEIN CHOICE study: Continued rivaroxaban therapy significantly reduced the rate of recurrence in patients with provoked and unprovoked VTE compared with aspirin

 

This provides Cameron’s doctor with the option to tailor treatment to his individual risk profile in the extended treatment period, whilst providing him with the continued convenience of a once-daily regimen. Further information on single-drug approaches for VTE can be found here.

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Rivaroxaban offers a choice of two doses for extended treatment5

Summary

Looking more carefully at an individual’s risk of recurrence could help to identify patients who might benefit from extended anticoagulation.

 

Given the available evidence and guideline recommendations, extending treatment for patients like Cameron who are at clinical equipoise for continued anticoagulation may be beneficial. It may also provide the reassurance that individual’s like Cameron need to continue their lives, whilst not having to worry about whether they are protected from further thromboembolic events.

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