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Consider the needs of the following patient:
What should you consider when choosing a DVT treatment for Mathilde?
The non-vitamin K antagonist oral anticoagulants (NOACs; apixaban, dabigatran, edoxaban, rivaroxaban) are named as first-line treatments for DVT in patients without cancer by both the European Society of Cardiology (ESC) and the American College of Chest Physicians (ACCP).1,2
But these two treatments also differ in the acute phase. For apixaban, intensified dosing is administered for the first 7 days.7 On the other hand, patients receive intensified dosing of rivaroxaban for 21 days based on data showing that this provides equivalent thrombus regression to pretreatment with parental anticoagulation followed by a vitamin K antagonist.6,8
*In patients with moderate (CrCl30–49 ml/min) or severe (CrCl15– 29 ml/min) renal impairment, a reduction of rivaroxaban dose from 20 mg once daily to 15 mg once daily should be considered if the patient’s assessed risk for bleeding outweighs the risk for recurrent DVT and PE;
One such factor is an avoidance of parenteral therapy. So, for a patient like Mathilde who is averse to injections, rivaroxaban or apixaban may be the best choice.2
Another factor to consider is dosing schedule and if once-daily dosing is preferred, rivaroxaban would then be selected over apixaban.2
Another important treatment decision would need to be made after 3 months.
The ACCP recommend continuing anticoagulation after 3 months for patients with a first unprovoked venous thromboembolism (VTE) and low or moderate bleeding risk, and cessation of anticoagulation after 3 months for patients with VTE provoked by surgery or non-surgical transient risk factors.2 The ESC recommend an individualized approach that takes into account the risk of recurrence versus the risk of bleeding.1
In Mathilde’s case, it could be that the DVT was provoked by the short period of time that she was bedridden, but could that be a coincidence? Both her age and her BMI may increase the risk of recurrent VTE and it is also necessary to understand exactly how mobile she is in her day-to-day life.9
Further information on optimizing the duration of anticoagulation can be found here.
As always with decisions to anticoagulate, the benefits and risks of each treatment regimen must be well understood. The only way to do this, is to get to know the patient and consider them as an individual.
Because every patient is different.
Mathilde’s preference to avoid daily injections means that a parenteral treatment may not be suitable. However, other patients may be reassured by having family members or healthcare professionals visiting to administer their treatment, despite the burden that comes with injections.
As well as patient preference, factors such as comorbidities and the likelihood of treatment compliance need to be considered when choosing a regimen.
Only by taking everything into account is it possible to ensure that patients get the treatment that is right for them.