From the Research
For a patient with acute arterial stroke and erythrocytosis (awaiting JAK2 results, with low erythropoietin) who is currently on aspirin, a direct oral anticoagulant (DOAC) is generally preferred over low molecular weight heparin (LMWH). This recommendation is based on the most recent and highest quality evidence available, which suggests that DOACs offer several advantages in this clinical scenario, including consistent anticoagulation with fixed dosing, no requirement for regular monitoring, and demonstrated efficacy in preventing recurrent strokes in patients with arterial thrombosis 1.
The patient should continue aspirin 81mg daily alongside the DOAC for comprehensive antithrombotic coverage. However, this recommendation assumes normal renal function and absence of contraindications. The combination of erythrocytosis with low erythropoietin and pending JAK2 mutation testing suggests possible polycythemia vera, which increases thrombotic risk. DOACs work by directly inhibiting factor Xa or thrombin, providing more predictable anticoagulation than LMWH, which requires subcutaneous injections and works through antithrombin.
Some studies have suggested that LMWH may be beneficial in certain subgroups of patients, such as those with non-cardioembolic stroke or large-artery occlusive disease 2, 1. However, these findings are not consistent across all studies, and the overall evidence suggests that DOACs are a better choice for most patients with acute arterial stroke and erythrocytosis.
Regular complete blood counts should be monitored, and hematology consultation is advised for potential cytoreductive therapy depending on JAK2 results. It is also important to note that the choice of anticoagulant should be individualized based on the patient's specific clinical characteristics and risk factors.
In terms of specific DOACs, apixaban (5mg twice daily) or rivaroxaban (20mg daily with food) may be suitable options, although the choice of DOAC should be based on the patient's individual needs and circumstances. Overall, the use of DOACs in patients with acute arterial stroke and erythrocytosis has the potential to improve outcomes and reduce the risk of recurrent strokes.