From the Guidelines
For a 75-year-old male with bilateral leg edema who has a history of DVT in 2017 and is currently on Xarelto (rivaroxaban), without heart failure or kidney disease, I recommend continuing the Xarelto as prescribed for DVT prevention while adding measures to manage the edema. This recommendation is based on the most recent and highest quality study, which suggests that anticoagulant therapy with direct oral anticoagulants (DOACs) such as rivaroxaban is effective in preventing recurrent VTE 1. The patient's current medication, Xarelto (rivaroxaban), is a DOAC that has been shown to be effective in preventing recurrent VTE, and its continuation is recommended as long as the patient does not have any contraindications or increased risk of bleeding 1. To manage the bilateral leg edema, I recommend the following measures:
- Elevate the legs above heart level for 30 minutes, 3-4 times daily
- Wear compression stockings (20-30 mmHg) during waking hours, putting them on first thing in the morning before getting out of bed
- Limit salt intake to less than 2,000 mg daily and maintain adequate hydration with 6-8 glasses of water per day
- Regular walking or other low-impact exercise for 30 minutes daily can improve circulation These measures can help reduce fluid accumulation and improve venous return, which can help alleviate the edema. It is also important to note that the patient's history of DVT and current edema may be related to venous insufficiency, which is a common complication of DVT 1. If the edema persists or worsens despite these measures, further evaluation would be warranted to rule out other causes or consider adding a mild diuretic.
From the Research
Patient Profile
- 75-year-old male with bilateral leg edema
- History of deep vein thrombosis (DVT) in 2017
- Currently on Xarelto (rivaroxaban)
- No heart failure or kidney disease
Relevant Studies
- A study published in 2014 2 found that rivaroxaban is a reasonable alternative to standard therapy for the treatment of DVT and pulmonary embolism, with a lower rate of major bleeding compared to enoxaparin-VKA.
- A 2021 study 3 reported that rivaroxaban is a viable option for anticoagulation in patients with cardiovascular disease and renal impairment, but requires careful assessment of benefits and risks.
- A 2019 review 4 stated that direct oral anticoagulants (DOACs), including rivaroxaban, are the preferred treatment for DVT due to their efficacy, safety, and convenience.
Treatment and Management
- Rivaroxaban has been shown to be effective in treating DVT, with a low risk of recurrent venous thromboembolism and major bleeding 2, 5.
- The use of rivaroxaban in patients with renal impairment requires careful monitoring and dose adjustment 3.
- A study published in 2020 6 found that adding diosmin 600 to rivaroxaban and elastic compression stockings reduced the risk of post-thrombotic syndrome after femoropopliteal DVT.
Key Findings
- Rivaroxaban is a safe and effective treatment for DVT, with a low risk of major bleeding and recurrent venous thromboembolism.
- Patients with renal impairment require careful monitoring and dose adjustment when using rivaroxaban.
- The addition of diosmin 600 to rivaroxaban and elastic compression stockings may improve clinical and ultrasound outcomes in patients with femoropopliteal DVT.