What is the optimal management for a patient with acute arterial stroke and erythrocytosis, awaiting JAK2 (Janus kinase 2) results, with low erythropoietin levels, currently on aspirin, regarding the choice between Direct Oral Anticoagulant (DOAC) and Low Molecular Weight Heparin (LMWH), and between hydroxyurea and phlebotomy (venesections) for reducing erythrocyte burden?

From the Guidelines

For a patient with acute arterial stroke and erythrocytosis, I strongly recommend using a direct oral anticoagulant (DOAC) over low molecular weight heparin (LMWH) for long-term management, along with cytoreductive therapy using hydroxyurea rather than venesection alone. This approach prioritizes reducing the risk of further thrombotic events while managing the erythrocytosis, considering the patient's low erythropoietin levels and pending JAK2 mutation results, which may indicate an underlying myeloproliferative disorder like polycythemia vera 1. Given the lack of specific guidance on DOACs versus LMWH in the context of acute arterial stroke with erythrocytosis in the provided evidence, the decision leans on the general principles of anticoagulation in stroke management and the benefits of DOACs in terms of stability and reduced monitoring requirements.

Key considerations for this patient include:

• Continuing aspirin 81mg daily alongside the chosen anticoagulant, as aspirin is recommended for patients with acute ischemic stroke to reduce mortality and morbidity, provided there are no contraindications 1.
• Selecting a DOAC such as apixaban (5mg twice daily) or rivaroxaban (20mg daily) for their favorable profiles in terms of efficacy, safety, and convenience.
• Initiating hydroxyurea (starting at 500-1000mg daily, adjusted to maintain hematocrit <45% and platelets <400,000/μL) for cytoreduction, as it addresses the underlying myeloproliferation, reduces all cell lines, and has anti-thrombotic effects beyond simple cytoreduction.
• Monitoring complete blood counts every 2-4 weeks initially, then every 3 months once stable, to adjust hydroxyurea dosing as needed and prevent complications.
• Ensuring adequate hydration and considering the addition of allopurinol to prevent hyperuricemia when initiating cytoreductive therapy.

This approach balances the need to prevent further thrombotic events with the management of erythrocytosis, prioritizing the patient's morbidity, mortality, and quality of life outcomes.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Acute Arterial Stroke with Erythrocytosis

• The management of acute arterial stroke involves timely reperfusion treatment, which requires early recognition of symptoms and efficient assessment by the attending stroke team 2.
• Patients with acute ischemic stroke should be admitted directly to an acute stroke unit for close monitoring and prevention of secondary complications 2, 3.
• The use of erythropoiesis-stimulating agents (ESAs) has been associated with an increased risk of acute stroke in patients with chronic kidney disease, particularly in those with cancer 4.

Anticoagulation Therapy

• The choice between DOAC (Direct Oral Anticoagulant) and LMWH (Low Molecular Weight Heparin) for anticoagulation therapy in patients with acute arterial stroke and erythrocytosis is not explicitly stated in the provided studies.
• However, guidelines for the management of acute ischemic stroke recommend the use of anticoagulation therapy to prevent secondary strokes, but do not specify a particular type of anticoagulant 5, 2.

Reduction of Erythrocytosis Burden

• The reduction of erythrocytosis burden can be achieved through various methods, including venesections and hydroxyurea 6.
• Venesections are a common method for reducing red blood cell mass in patients with erythrocytosis, while hydroxyurea is a medication that can help reduce erythrocytosis by decreasing erythropoiesis.
• The choice between venesections and hydroxyurea depends on the underlying cause of erythrocytosis and the patient's individual needs, but is not explicitly stated in the provided studies.

Diagnostic Evaluation

• The diagnostic evaluation of erythrocytosis involves measurement of erythropoietin levels, which can help distinguish between primary and secondary causes of erythrocytosis 6.
• Further investigation, including mutational testing and bone marrow biopsy, may be necessary to determine the underlying cause of erythrocytosis.