High bleeding and clotting risk conditions- Difficult DOAC case study

 

Examples of patients with AF at very high risk of stroke or systemic embolism: • CHADS2 ≥4 • Valvular AF (mechanical valve and/or moderate‐severe mitral stenosis) • Transient ischemic attack or ischemic stroke within the past 3 months

Examples of patients with a history of VTE at very high risk of recurrent thrombosis: • VTE within the past 3 months • History of recurrent VTE after anticoagulation is stopped • Triple positive antiphospholipid antibody syndromea • Heparin‐induced thrombocytopenia within 3 months • Active cancer with history of cancer‐associated thrombosis

Examples of patients at very high bleeding risk: • Multiple risk factors for bleeding (e.g., extreme age, advanced kidney disease) • Thrombocytopenia (platelets less than 50) • Unresected gastrointestinal tumours • Angiodysplasia • Severe colitis • Lobar ICH secondary to cerebral amyloid angiopathy

https://www.jthjournal.org/article/S1538-7836(22)00495-0/fulltext

1. Dose reduce Apixaban to 2.5 mg BID if high risk of clotting and high risk of bleeding. If Afib consider if candidate for Watchman

Discussion for patients with VTE

VTE affects 1–2 per 1000 persons each year and has a lifetime risk of 8% after age 45. Upto 50% of VTE can be unprovoked. 

1. Risk of recurrence and impact of anticoagulation: 10% risk of recurrent VTE in year 1 and 2, 30% recurrence in 5 years if AC discontinued. 80-90% reduction in risk of recurrence with anticoagulation.

2. Other complications of VTE that are chronic besides recurrent VTE: 

•  PTS risk : 20% to 50% incidence ( ipsilateral DVT recurrence is associated with a 4–6 times increased risk of PTS)
• 0.1 to 4% risk of CTEPH after PE  

3. Long term anticoagulation options: DOAC versus aspirin. Data from 2 trials: AMPLIFY- EXT and EINSTEIN choice suggest that reduced dose can be used with equal efficacy. ASH 2020 guideline: For patients with DVT and/or PE who have completed primary treatment and will continue with a DOAC for secondary prevention, the ASH guideline panel suggests using standard dose DOAC or lower dose DOAC. European guidelines suggest reduced dose after  6-12 months after full dose.

4. Who should consider full dose rather than reduced dose for long term anticoagulation?

Patients with any of the following should continue on full dose anticoagulation:  AFib, recurence on DOAC in the past, initial thrombotic event was life threatening or with hemodynamic compromise, chronic TEPH, severe post thrombotic syndrome, active cancer and obesity.

5. HERDOO 2 risk evaluation in women with unprovoked VTE: if high, ct standard dose