What is the recommended anticoagulation therapy for a 76-year-old male with a history of Factor V Leiden deficiency and a previous Deep Vein Thrombosis (DVT) with a positive DVT on ultrasound?

Anticoagulation Management for 76-Year-Old Male with Factor V Leiden and Recurrent DVT

For a 76-year-old male with Factor V Leiden deficiency and recurrent DVT confirmed on ultrasound, extended-phase anticoagulation with a direct oral anticoagulant (DOAC) is strongly recommended with no scheduled stop date.

Initial Treatment Phase

• A minimum 3-month treatment phase of anticoagulation is required for all patients with acute VTE 1
• For the initial treatment phase (first 3 months):
  • Preferred: Direct oral anticoagulant (DOAC) such as apixaban, rivaroxaban, edoxaban, or dabigatran
  • If DOAC is contraindicated: Vitamin K antagonist (warfarin) with target INR 2.0-3.0

Extended-Phase Anticoagulation

• After completing the initial 3-month treatment phase, this patient requires extended-phase anticoagulation (no scheduled stop date) due to:

  • Recurrent DVT (previous history plus current presentation)
  • Factor V Leiden deficiency (persistent risk factor)
  • Advanced age (76 years) increasing both recurrence and mortality risk

• The recommended extended-phase regimen:

  • First choice: Reduced-dose DOAC (apixaban 2.5 mg twice daily or rivaroxaban 10 mg once daily) 1
  • Second choice (if DOAC contraindicated): Vitamin K antagonist (warfarin) with target INR 2.0-3.0 1, 2

Rationale for Extended Anticoagulation

1. The patient has Factor V Leiden, which is classified as a persistent risk factor for VTE 1, 3
2. The patient has recurrent DVT, indicating high risk for future events 3, 4
3. The 2021 CHEST guidelines strongly recommend extended-phase anticoagulation for VTE diagnosed in the absence of transient provocation or with persistent risk factors 1
4. For patients with Factor V Leiden and documented DVT, extended anticoagulation is suggested, especially with recurrent events 3, 2

Monitoring Recommendations

• For patients on DOACs:

  • No routine coagulation monitoring required
  • Annual reassessment of risks/benefits of continued anticoagulation 1
  • Periodic renal function assessment
  • Reassessment at times of significant health status changes

• For patients on warfarin:

  • Regular INR monitoring to maintain target INR 2.0-3.0
  • Annual reassessment of risks/benefits 1

Important Considerations

• The risk of major bleeding with anticoagulation is approximately 1-3% per year 1, 3, but this is outweighed by the high risk of recurrent VTE in this patient
• DOACs have been shown to reduce the rate of major bleeding compared to conventional anticoagulation (OR 0.63,95% CI 0.45 to 0.89) 5
• Reduced-dose DOACs (apixaban 2.5 mg BID or rivaroxaban 10 mg daily) are suggested over full-dose regimens for extended therapy 1
• Extended anticoagulation does not have a predefined stop date, but should be reassessed at least annually 1

Special Considerations for Factor V Leiden

• Heterozygous carriers have approximately 3.5-fold increased risk of VTE, while homozygous carriers have approximately 18-fold increased risk 3
• For patients with Factor V Leiden and recurrent VTE, indefinite anticoagulation is recommended 3, 6
• The FDA label for warfarin specifically mentions that for patients with documented Factor V Leiden mutation and DVT, treatment for 6-12 months is recommended and indefinite therapy is suggested for idiopathic thrombosis 2

This patient's combination of advanced age, Factor V Leiden deficiency, and recurrent DVT places him at high risk for future thrombotic events, making extended-phase anticoagulation with a DOAC the most appropriate management strategy to reduce morbidity and mortality.