Should a patient in their mid-90s with a history of partial DVT, recently treated with Lovenox (enoxaparin) for 21 days and scheduled to start aspirin, be on long-term anticoagulation therapy?

From the Guidelines

The patient in their mid-90s with a history of partial DVT, recently treated with Lovenox for 21 days and scheduled to start aspirin, should not automatically be placed on long-term anticoagulation therapy without considering their individual risk factors and bleeding risk assessment. Given the patient's advanced age, the risk of bleeding complications is a significant concern. The decision to extend anticoagulation or transition to aspirin should be personalized, taking into account the patient's full medical history, including prior clotting events, mobility status, renal function, and medication interactions 1. For patients with unprovoked DVT, the treatment duration depends on the bleeding risk assessment, which is likely high in this patient due to their age. The American Society of Hematology 2020 guidelines suggest that anticoagulation is more effective than aspirin in preventing recurrent VTE but also acknowledge the increased risk of bleeding complications with extended anticoagulant therapy 1. A more recent study from 2021 discusses the use of reduced doses of anticoagulants and low-dose aspirin as approaches to prevent VTE recurrence with a reduced risk for bleeding 1. However, an older study from 2008 emphasizes the importance of long-term anticoagulation in preventing recurrent VTE events, especially in patients with cancer, but also notes the need for balancing the risk of recurrence with the risk of bleeding complications 1. Considering the most recent and highest quality evidence, the patient should be closely monitored for signs of recurrent DVT or bleeding complications, and the decision for long-term anticoagulation should be made on a case-by-case basis, weighing the benefits of preventing future clots against the risks of bleeding 1. Key factors to consider include the patient's mobility status, renal function, and history of prior clotting events, as these will influence the risk of recurrence and bleeding. Regular reassessment of the patient's condition and adjustment of their treatment plan as necessary is crucial in managing their care effectively.

From the Research

Patient Considerations

• The patient is in their mid-90s with a history of partial DVT, recently treated with Lovenox (enoxaparin) for 21 days, and is scheduled to start aspirin.
• The decision to extend anticoagulation therapy should be based on the individual's risk of recurrent VTE and bleeding complications, as well as patient preference 2.

Treatment Options

• Low-dose direct oral anticoagulants (DOACs) such as apixaban and rivaroxaban have been shown to be effective and safe for secondary VTE prophylaxis in patients at high risk of VTE recurrence 3.
• Rivaroxaban has been approved for the initial treatment of DVT and PE, as well as the prevention of recurrent DVT and PE, and has been shown to be noninferior to standard therapy consisting of subcutaneous enoxaparin sodium overlapping with and followed by an oral dose-adjusted vitamin K antagonist (enoxaparin-VKA) 4.
• Aspirin has been compared to rivaroxaban for extended treatment of VTE, and rivaroxaban has been shown to have a significantly lower risk of recurrent VTE compared to aspirin, without a significant increase in bleeding rates 5.

Risk Assessment

• The risk of recurrent VTE can be estimated through a two-step decision algorithm, taking into account the features of the patient, the initial event, and associated conditions, as well as D-dimer levels and residual thrombosis at the time of anticoagulant treatment discontinuation 6.
• Patients with a high risk of recurrence, such as those with active cancer or a second unprovoked VTE, may benefit from indefinite anticoagulation, while those with a low risk of recurrence may be treated for a shorter duration 2.

Recommendations

• Based on the available evidence, the patient may benefit from extended anticoagulation therapy with a low-dose DOAC such as rivaroxaban, in addition to aspirin, to reduce the risk of recurrent VTE 3, 4, 5.
• However, the decision to extend anticoagulation therapy should be individualized, taking into account the patient's risk of recurrence and bleeding complications, as well as patient preference 2.