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This TRC Hot Topic webcast features an expert panel discussion and clinical guidance for treatment of venous thromboembolism. Listen as Sam Schulman, MD, FRCPC(C) and other panelists discuss and answer common clinical questions, including:

  • Which anticoagulant or DOAC is preferred?
  • How long should anticoagulation be used?
  • When might a low-dose DOAC be considered long-term?
  • How should you manage patients who get a VTE on anticoagulation?

Here’s an excerpt of the
Venous Thromboembolism Treatment webcast:

Lori Dickerson: We’re writing about this topic now because we’re getting questions about treating VTE, and it’s coming up because of new guidelines from the American Society of Hematology. And, of course, we’re also familiar with the American College of Chest Physicians guidelines surrounding antithrombotic therapy, and our guest Sam Schulman has contributed to many of these publications.

So, Sam, if you could kick us off and start our discussion by briefly summarizing why DOACs are preferred as anticoagulants for the treatment of VTE.

Sam SchulmanThank you. DOACs are very easy to manage, and as everyone probably knows, there is no laboratory monitoring. We need to make sure, of course, that the creatinine is within certain parameters, but except for that, it’s as easy as can be today.

The problem with warfarin is that it’s mainly unstable in the beginning, but the beginning of the treatment of deep vein thrombosis or pulmonary embolism is the most critical. It’s when the clot is fresh that there’s the highest risk of propagation or recurrence.

So, if we’re not managing the warfarin correctly and getting it in the range, then the patient is at high risk. I think that several of the studies show when they compared the new anticoagulants versus warfarin, that the difference in event rates, whether it was bleeding or blood clots, was mainly in the beginning. And then, the longer you go, then the curves become parallel.  

Lori Dickerson: That’s a great introduction, Sam. I appreciate that.

Andrea, in your primary care practice, have you moved most of your primary care patients from warfarin to a DOAC given the ease of use, or is cost really still a significant barrier?

Andrea Darby-Stewart: That’s a great question. I’m certainly diligently working to move our patients off of warfarin onto DOACs. I actually manage our warfarin registry for the residency program, so the added challenge of having residents manage warfarin and keep track of those patients is certainly inspiring us to try and move our patients.

We do have patients who are on sliding scale who can access the medications at a much lower cost, and it’s been very nice over the last couple of years where it’s been much less challenging to get prior authorizations through our Medicaid and Medicare Advantage programs, so patients are less resistant from a cost standpoint.

Lori Dickerson: Appreciate that introduction to get us started. 

Sam, I do want to talk about specific choice of DOAC next. We do make the recommendation to choose Eliquis or Xarelto (apixaban or rivaroxaban) as the preferred DOACs for treatment of VTE. Would you agree with these choices, given that, of course, there aren’t really head-to-head comparisons among the DOACs?

Sam SchulmanHowever, if the patient has been in the hospital and treated there with heparin or low-molecular-weight heparin for at least five days, then we can also use the others, because both Savaysa 
and Pradaxa (or edoxaban and dabigatran) are okay to use after the lead-in. If the patients have been in the hospital, then we can choose whichever.

Edoxaban is very easy because it’s once a day, and it doesn’t have to be taken with food, either. Rivaroxaban has to be taken with food. So it’s really the easiest one of them all, for the patient.

Lori Dickerson: Okay, that’s a good perspective. We have Pradaxa and Savaysa noted there in our article, about the need for overlap, so I think we’ve covered that.

Okay, let’s move on to our next question, which is about how long to use an anticoagulant. We recommend treating with a full-dose anticoagulant for three to six months.

So, Sam, the question I have for you is: when do you choose three months versus six months? How do you pick from that window?

Sam SchulmanWe often feel that patients with pulmonary embolism have a more serious disease than patients with deep vein thrombosis. I think most clinicians tend to give patients with PE six months and then make a decision whether to stop or continue, whereas with DVT, especially if it’s distal DVT or even just popliteal, then shorter makes us quite comfortable. 

Indeed, pulmonary embolism has a higher mortality, and we are starting to say that they’re not one and the same disease. For thirty years, we have said, “It’s venous thromboembolism. Those who have DVT, many or most of them have PE, and those who have pulmonary embolism, 70% of them, we can see a clot in the leg,” but it isn’t exactly like that. Some pulmonary emboli come from the right side of the heart, and some, as we are starting to see now, occur directly in the lung, in association with severe inflammatory disease.

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