From the Guidelines
For an 82-year-old female with right lower extremity deep vein thrombosis (DVT), the recommended treatment is anticoagulation therapy with a direct oral anticoagulant (DOAC) such as apixaban, dabigatran, edoxaban, or rivaroxaban, as these have been shown to be superior to vitamin K antagonists (VKAs) in the treatment-phase anticoagulant therapy 1.
Treatment Options
The following treatment options are available:
- Direct oral anticoagulants (DOACs) such as apixaban (5 mg twice daily for 7 days, then 2.5 mg twice daily), rivaroxaban (15 mg twice daily for 21 days, then 20 mg once daily), or edoxaban (60 mg once daily after 5-10 days of parenteral anticoagulation) are preferred options due to their fixed dosing and no need for routine monitoring.
- Low molecular weight heparin (LMWH) such as enoxaparin (1 mg/kg twice daily or 1.5 mg/kg once daily) is an alternative, particularly if there are concerns about oral intake or absorption.
- Warfarin (target INR 2-3) is another option but requires regular INR monitoring and has more drug-drug interactions.
Treatment Duration and Monitoring
- Treatment duration should be at least 3 months, with consideration for extended therapy based on risk factors for recurrence versus bleeding risk 1.
- The presence of active cancer, ongoing cancer treatment, an unprovoked DVT, or persistent thrombosis are reasons to consider continuation of anticoagulation.
- For this elderly patient, renal function should be assessed before prescribing, and dose adjustments may be necessary.
- Compression stockings (20-30 mmHg) should be considered for symptom relief.
- The patient should be educated about signs of bleeding complications and recurrent thrombosis.
Rationale
Anticoagulation prevents thrombus extension and reduces the risk of pulmonary embolism by inhibiting the coagulation cascade, allowing the body's natural fibrinolytic system to gradually dissolve the existing clot. The NCCN panel recommends that the effectiveness of anticoagulation in patients with established DVT be monitored clinically during and after treatment 1.
From the FDA Drug Label
The efficacy of XARELTO was demonstrated in the EINSTEIN DVT study, a multi-national, open-label, non-inferiority study comparing XARELTO (at an initial dose of 15 mg twice daily with food for the first three weeks, followed by XARELTO 20 mg once daily with food) to enoxaparin 1 mg/kg twice daily for at least five days with VKA and then continued with VKA only after the target INR (2.0–3.0) was reached. In the EINSTEIN DVT study, XARELTO was demonstrated to be non-inferior to enoxaparin/VKA for the primary composite endpoint of time to first occurrence of recurrent DVT or non-fatal or fatal PE [EINSTEIN DVT HR (95% CI): 0.68 (0.44,1.04)].
The treatment for an 82-year-old female with right lower extremity DVT is Rivaroxaban (XARELTO), with an initial dose of 15 mg twice daily for the first three weeks, followed by 20 mg once daily. 2
From the Research
Treatment Options for Deep Vein Thrombosis (DVT)
The treatment for an 82-year-old female with right lower extremity DVT typically involves anticoagulation therapy. The main goal of treatment is to prevent the clot from growing and causing a pulmonary embolism, as well as to reduce the risk of recurrent DVT.
Anticoagulation Therapy
- Anticoagulation is the mainstay of DVT treatment, and most patients can be treated in the outpatient setting with low-molecular-weight heparin and a vitamin K antagonist (warfarin) or direct-acting oral anticoagulants 3.
- Direct-acting oral anticoagulants, such as rivaroxaban and apixaban, have been shown to be effective and safe for the treatment of DVT, with significant reductions in major bleeding 4.
- Unfractionated heparin is used if a patient is hemodynamically unstable or has severe renal insufficiency, high bleeding risk, hemodynamic instability, or morbid obesity 3.
Duration of Therapy
- Current guidelines recommend anticoagulation for a minimum of three months 3.
- The optimal duration of therapy is dictated by the presence of modifiable thrombotic risk factors, and long-term anticoagulation should be considered in patients with unprovoked VTE or persistent prothrombotic risk factors such as cancer 5.
Special Considerations
- Symptomatic distal DVT should be treated with anticoagulation, but asymptomatic patients may be monitored with serial imaging for two weeks and treated only if there is extension 3.
- Thrombolytic therapy is reserved for massive pulmonary embolism or extensive DVT, and inferior vena cava filters are reserved for patients with acute VTE and contraindications to anticoagulation 5.