How to treat a patient with elevated factor VIII (Coagulation factor VIII) levels and a history of Deep Vein Thrombosis (DVT) long-term?

From the Guidelines

Long-term treatment for patients with elevated Factor VIII levels and a history of DVT typically involves indefinite anticoagulation therapy with a direct oral anticoagulant (DOAC) such as apixaban (5 mg twice daily), rivaroxaban (20 mg daily with food), edoxaban (60 mg daily), or dabigatran (150 mg twice daily) as the preferred medication, as suggested by the most recent guidelines 1. The choice between these options depends on patient-specific factors including renal function, drug interactions, cost, and patient preference. Regular monitoring of renal function is necessary for patients on DOACs, while warfarin requires routine INR monitoring. Elevated Factor VIII is considered a thrombophilic condition that increases the risk of recurrent thrombosis, justifying long-term anticoagulation. The risk of recurrent DVT in these patients is significantly higher than in the general population, and the benefit of preventing recurrent thrombosis typically outweighs the bleeding risk associated with anticoagulation, as supported by previous studies 2, 3, 4. Patients should also be counseled on modifiable risk factors such as smoking cessation, weight management, and avoiding prolonged immobility to further reduce thrombosis risk. It is also important to consider the patient's individual circumstances and preferences when choosing an anticoagulant, as outlined in the guidelines 4. Overall, the goal of long-term anticoagulation therapy is to prevent recurrent thrombosis and reduce the risk of morbidity and mortality associated with DVT, while minimizing the risk of bleeding complications.

Some key points to consider when selecting an anticoagulant include:

• The patient's renal function, as some anticoagulants may be contraindicated in patients with severe renal impairment 4
• The patient's history of bleeding or bleeding risk, as some anticoagulants may be more likely to cause bleeding complications 2, 3
• The patient's lifestyle and preferences, as some anticoagulants may require more frequent monitoring or have specific dietary restrictions 4
• The patient's other medical conditions, such as cancer or liver disease, which may affect the choice of anticoagulant 4

By considering these factors and choosing the most appropriate anticoagulant, healthcare providers can help patients with elevated Factor VIII levels and a history of DVT reduce their risk of recurrent thrombosis and improve their overall quality of life.

From the FDA Drug Label

For patients with a first episode of DVT or PE who have documented deficiency of antithrombin, deficiency of Protein C or Protein S, or the Factor V Leiden or prothrombin 20210 gene mutation, homocystinemia, or high Factor VIII levels (>90th percentile of normal), treatment for 6 to 12 months is recommended and indefinite therapy is suggested for idiopathic thrombosis

• Long-term treatment for a patient with elevated factor VIII levels and a history of DVT is suggested to be indefinite therapy with warfarin, with a target INR of 2.5 (INR range, 2.0 to 3.0) 5.
• The risk-benefit should be reassessed periodically in patients who receive indefinite anticoagulant treatment.

From the Research

Treatment Options for Patients with Elevated Factor VIII Levels and History of DVT

• Long-term anticoagulation may be appropriate for patients with elevated factor VIII levels and a history of deep vein thrombosis (DVT) 6.
• New oral anticoagulants, such as dabigatran, rivaroxaban, and apixaban, have been shown to be effective for the long-term treatment of venous thromboembolism (VTE) 7, 8.
• These new oral anticoagulants have a favorable net clinical benefit, considering both efficacy and bleeding complications 7.
• Rivaroxaban, apixaban, and dabigatran are more effective than placebo for the extended treatment of VTE 7.
• Elevated factor VIII levels (>150 IU/dL) increase the risk of venous thrombosis, and levels above 200 IU/dL are associated with DVT recurrence 9.

Considerations for Long-Term Treatment

• The optimal duration of secondary thromboprophylaxis for patients with high factor VIII levels is uncertain 10.
• Reduction of factor VIII by administration of a non-selective β-receptor blocker might be a promising therapeutic concept, but further research is needed 10.
• Patients with elevated factor VIII levels and a history of DVT may require ongoing monitoring and adjustment of their anticoagulation therapy to minimize the risk of recurrent VTE 9, 6.