What is the best anticoagulant regimen for a patient with a history of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) who has failed treatment with heparin and Eliquis (apixaban)?

From the Guidelines

For a patient with a history of DVT and PE who has failed treatment with heparin and apixaban, the most appropriate alternative anticoagulant regimen is warfarin, with a target INR of 2.0-3.0, as recommended by the 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism 1. The standard regimen involves initiating warfarin at 5 mg daily with dose adjustments based on INR monitoring. During the transition, overlap with parenteral anticoagulation (such as enoxaparin 1 mg/kg twice daily) is necessary until the INR reaches the therapeutic range for at least 24 hours. Some key points to consider in the management of such patients include:

• Treatment duration depends on whether this is a recurrent event, with at least 3-6 months for a first recurrence and potentially indefinite therapy for multiple events, as suggested by the 2014 ESC guidelines 1.
• Alternative options include rivaroxaban (15 mg twice daily for 21 days, then 20 mg daily) or dabigatran (150 mg twice daily after 5-10 days of parenteral anticoagulation), as mentioned in the 2014 Mayo Clinic Proceedings article 1.
• For patients with cancer-associated thrombosis, low molecular weight heparin such as dalteparin (200 IU/kg daily for month 1, then 150 IU/kg daily) may be more effective, according to the 2014 ESC guidelines 1.
• Treatment failure with multiple anticoagulants warrants investigation for underlying conditions like antiphospholipid syndrome, cancer, or anatomical abnormalities, as highlighted in the 2019 ACR appropriateness criteria 1. Regular monitoring and specialist consultation are essential for managing these complex cases. Key considerations in choosing an anticoagulant regimen include the patient's risk of recurrent VTE, risk of anticoagulant-related bleeding, and the presence of any underlying conditions that may affect the choice of anticoagulant. In general, the choice of anticoagulant should be individualized based on the patient's specific clinical characteristics and preferences, as recommended by the 2019 ACR appropriateness criteria 1.

From the Research

Anticoagulant Regimens for Patients with DVT and PE

The patient in question has a history of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) and has failed treatment with heparin and Eliquis (apixaban). Considering this, the best anticoagulant regimen would be one that is effective in preventing recurrent VTE and has a lower risk of bleeding complications.

Alternative Anticoagulants

• Rivaroxaban has been shown to be noninferior to standard therapy in the treatment of DVT and PE, with a lower risk of major bleeding 2, 3.
• Apixaban, although failed in this patient, is generally considered effective in the treatment of VTE, but there are some populations where its use has not been extensively studied 4.
• Other direct oral anticoagulants (DOACs) such as dabigatran and edoxaban have also been shown to be effective in the treatment of VTE, with a lower risk of bleeding complications compared to standard therapy 5.

Considerations for Treatment

• The duration of anticoagulant treatment should be based on the estimated individual risk for recurrent VTE, with all patients receiving oral anticoagulant treatment for at least three months 6.
• The risk of recurrence after stopping therapy is largely determined by whether the acute episode of VTE has been effectively treated and by the patient's intrinsic risk of having a new episode of VTE 6.
• Patients with a history of recurrent VTE or those with a high risk of recurrence may require extended anticoagulation, with regular monitoring of their condition and adjustment of their treatment regimen as needed 6, 5.