From the Guidelines
For patients with recurrent deep vein thrombosis (DVT), a comprehensive workup should be performed to identify underlying causes, and management typically involves extended anticoagulation therapy, often indefinitely, with options including direct oral anticoagulants, as recommended by the most recent guidelines 1. The initial evaluation should include a complete blood count, comprehensive metabolic panel, coagulation studies (PT/INR, PTT), and D-dimer testing. More specialized testing should include:
- Thrombophilia screening with protein C and S levels, antithrombin III activity, factor V Leiden mutation, prothrombin gene mutation, antiphospholipid antibodies, and homocysteine levels
- Screening for malignancy with age-appropriate cancer screenings, chest X-ray, and abdominal/pelvic imaging
- Evaluation for anatomical abnormalities with vascular ultrasound or CT/MR venography According to the American Society of Hematology 2020 guidelines, indefinite anticoagulation is recommended for patients with recurrent unprovoked VTE 1. The NCCN panel recommends a minimum anticoagulation duration of 3 months, with consideration of continuation of anticoagulation in the presence of active cancer, ongoing cancer treatment, an unprovoked DVT, or persistent thrombosis 1. Patients should be educated about:
- Compression stockings
- Leg elevation
- Regular exercise
- Maintaining adequate hydration The recurrence risk is highest in unprovoked DVT, presence of thrombophilia, active cancer, or anatomical abnormalities that impair venous return. Identifying and addressing these underlying factors is crucial for preventing further episodes. Direct oral anticoagulants, such as apixaban 5mg twice daily, rivaroxaban 20mg daily, dabigatran 150mg twice daily, or edoxaban 60mg daily, are preferred over warfarin for primary treatment of VTE 1.
From the FDA Drug Label
1.4 Reduction in the Risk of Recurrence of Deep Vein Thrombosis and/or Pulmonary Embolism XARELTO is indicated for the reduction in the risk of recurrence of DVT and/or PE in adult patients at continued risk for recurrent DVT and/or PE after completion of initial treatment lasting at least 6 months.
The workup for recurrent DVT may involve the use of XARELTO for the reduction in the risk of recurrence of DVT and/or PE in adult patients at continued risk for recurrent DVT and/or PE after completion of initial treatment lasting at least 6 months 2.
- Key points:
- XARELTO is indicated for the reduction in the risk of recurrence of DVT and/or PE.
- The patient should be at continued risk for recurrent DVT and/or PE.
- The initial treatment should have lasted at least 6 months.
From the Research
Recurrent DVT Workup
- The diagnosis of recurrent deep vein thrombosis (DVT) can be challenging, with only about 20-30% of patients with symptoms of recurrent DVT actually having the disease 3.
- Clinical signs of recurrent DVT can be confused with post-thrombotic syndrome, making accurate diagnosis reliant on imaging studies 4.
- Ultrasound criteria for diagnosing recurrent DVT include a new non-compressible vein or an increase in the diameter of a previously thrombosed vein segment by >4mm 4.
- An increase in diameter of <2mm enables recurrence to be ruled out, while an increase between 2 and 4mm is deemed equivocal 4.
- Other diagnostic imaging methods, such as direct thrombus magnetic resonance imaging, are currently under evaluation, but ultrasound remains the most useful test for diagnosing recurrent DVT 4.
Diagnostic Approach
- A multifaceted approach to diagnosis is recommended, including clinical assessment, evaluation of pre-test probability, and objective diagnostic testing 5.
- The pre-test probability of DVT can be assessed using a clinical decision rule, with patients stratified into "unlikely" or "likely" categories 5.
- If DVT is "unlikely", a D-dimer test can be used to exclude the diagnosis, while if DVT is "likely", compression ultrasound is recommended 5.
Anticoagulation Therapy
- Anticoagulation therapy is essential for the treatment of DVT, with direct oral anticoagulants (DOACs) such as rivaroxaban and apixaban being preferred due to their efficacy, safety, and convenience 6, 5.
- DOACs may require dose reduction or avoidance in patients with renal dysfunction, and should be avoided in pregnancy 5.
- Recent evidence suggests that DOACs may be used to treat DVT in patients with cancer, but with a higher risk of gastrointestinal bleeding 5.
- Deferring compression ultrasound imaging (CUS) with therapeutic doses of rivaroxaban has been shown to be a safe strategy in patients with suspected DVT 7.