Anticoagulation Regimen for DVT in Post-Stenting Patient on Dual Antiplatelet Therapy
For a patient with DVT 5 days post-RCA stenting who is currently on prasugrel and aspirin, the recommended anticoagulation regimen is to use a direct oral anticoagulant (DOAC) such as apixaban, dabigatran, edoxaban, or rivaroxaban while continuing clopidogrel and discontinuing aspirin (triple therapy should be limited to ≤1 week). 1
Initial Management
- Begin parenteral anticoagulation immediately with low molecular weight heparin (LMWH) or fondaparinux while transitioning to oral anticoagulation 1, 2
- Switch prasugrel to clopidogrel 75 mg daily, as prasugrel is not recommended as part of triple antithrombotic therapy due to increased bleeding risk 1
- Continue aspirin 75-100 mg daily for ≤1 week (shortest possible duration of triple therapy) 1
Recommended Anticoagulation Strategy
- After initial parenteral anticoagulation, transition to a DOAC (preferred over vitamin K antagonists) 1
- Options include:
Duration of Therapy
- For DVT treatment: minimum 3 months of anticoagulation 1
- For dual antithrombotic therapy (DOAC + clopidogrel): continue for up to 6 months post-stenting if not at high ischemic risk, or up to 12 months if at high ischemic risk 1
- After this period, discontinue clopidogrel and continue DOAC alone if ongoing anticoagulation is indicated 1
Risk Mitigation
- Prescribe a proton pump inhibitor for the duration of combined antithrombotic therapy to reduce gastrointestinal bleeding risk 1
- Monitor for signs of bleeding closely, especially during the period of dual or triple therapy 1
- Consider compression stockings for 2 years following DVT to prevent post-thrombotic syndrome 2
Important Considerations and Pitfalls
- Triple therapy (DOAC + aspirin + P2Y12 inhibitor) significantly increases bleeding risk and should be limited to the shortest possible duration (≤1 week) 1
- Prasugrel and ticagrelor are not recommended as part of triple therapy due to excessive bleeding risk 1, 3
- If the patient is at very high bleeding risk, consider shortening the duration of dual antithrombotic therapy to 1-3 months 1
- Regular reassessment of thrombotic and bleeding risks is essential throughout treatment 4
- Early mobilization rather than bed rest is recommended for patients with acute DVT 2
This approach balances the need for DVT treatment while minimizing the risk of stent thrombosis and major bleeding complications in this complex clinical scenario.