What is the evidence for discharging a patient with a common femoral Deep Vein Thrombosis (DVT) on outpatient Direct Oral Anticoagulant (DOAC) therapy?

From the Guidelines

Outpatient management of common femoral deep vein thrombosis (DVT) with direct oral anticoagulants (DOACs) can be considered in select patients, but it is not generally recommended as first-line approach due to the higher risk of complications. These proximal DVTs carry higher risk of complications including pulmonary embolism and post-thrombotic syndrome, typically warranting initial inpatient management 1. If considering outpatient DOAC therapy, patient selection is crucial - candidates should be hemodynamically stable, have low bleeding risk, good renal function, reliable follow-up capability, and adequate social support. For those who meet these criteria, standard DOAC regimens include rivaroxaban (15 mg twice daily for 21 days, then 20 mg daily), apixaban (10 mg twice daily for 7 days, then 5 mg twice daily), or edoxaban/dabigatran following 5-10 days of parenteral anticoagulation 1. Some key points to consider when selecting patients for outpatient DOAC therapy include:

• Hemodynamic stability
• Low bleeding risk
• Good renal function
• Reliable follow-up capability
• Adequate social support Treatment duration is typically 3-6 months minimum. Close follow-up within 1 week is essential, with clear instructions on warning signs requiring immediate medical attention. The physiological concern with common femoral DVTs is their proximity to the iliofemoral system and higher clot burden, which increases risk of propagation and embolization, explaining why many clinicians prefer initial hospitalization with possible interventional approaches before transitioning to outpatient management 1.

From the FDA Drug Label

Both studies were randomized, parallel-group, double-blind trials in patients with symptomatic proximal DVT and/or symptomatic PE. Patients with an objectively confirmed symptomatic DVT and/or PE were randomized to treatment with apixaban 10 mg twice daily orally for 7 days followed by apixaban 5 mg twice daily orally for 6 months, or enoxaparin 1 mg/kg twice daily subcutaneously for at least 5 days (until INR ≥2) followed by warfarin (target INR range 2.0-3. 0) orally for 6 months.

The evidence does not specifically address sending a patient home on outpatient DOAC therapy with a common femoral DVT. The studies mentioned in the label discuss proximal DVT and/or symptomatic PE, but do not provide information on the management of common femoral DVT. Therefore, no conclusion can be drawn about the safety and efficacy of apixaban for this specific condition 2.

From the Research

Outpatient DOAC Therapy for Common Femoral DVT

• The decision to send a patient home on outpatient DOAC therapy with a common femoral DVT depends on various factors, including the patient's overall health, renal function, and ability to adhere to the treatment regimen 3.
• Direct oral anticoagulants (DOACs) are considered a preferred treatment option for DVT due to their efficacy, safety, and convenience compared to warfarin 3, 4, 5.
• However, DOACs may require dose reduction or avoidance in patients with renal dysfunction, and should be avoided in pregnancy 3.
• For patients with iliofemoral DVT, which includes common femoral DVT, the risk-benefit profile is altered compared to proximal DVT without involvement of the common femoral or iliac draining veins 6.
• A strategy of thrombus removal, including thrombectomy, catheter-directed thrombolysis, and pharmacomechanical thrombolysis, may be considered for patients with acute iliofemoral DVT to improve long-term outcomes 6, 7.
• The use of DOACs in patients with cancer may be considered, but the risk of gastrointestinal bleeding is higher with DOACs than with low molecular weight heparin (LMWH) in patients with gastrointestinal cancer 3.