ACP 2021: Dr Stephan Moll covers the basics of DOAC duration for VTE, use of anticoagulation in special populations, and perioperative use of DOACs
How do you gauge a patient's "DOAC Hate Factor" and why is it important?
In his presentation "DOAC Dos and Don'ts" at the American College of Physicians Internal Medicine Meeting 2021: Virtual Experience, Stephan Moll, MD, spoke first about dosing and duration of treatment for venous thromoboembolism (VTE) using the "new" direct oral anticoagulants (DOACs) and then reviewed the approach to anticoagulant therapy in a range of special populations, including patients with obesity, with cancer, and renal compromise. He finishes his talk with a quick review of the evidence on perioperative anticoagulation.
Quantifying the "DOAC Hate Factor," he explains, is important when discussing continuation or discontinuation of anticoagulation therapy because patient preference has to be considered here. Once you know, on a scale from 0 to 10, how much hate there is, you can ask questions and try to accommodate where it's possible.
The slide show that follows is based on Dr Moll's presentation and includes links to many of the studies he mentions.
Direct oral anticoagulants (DOACs) in the treatment of VTE. In 2016, the American College of Chest Physicians recommended that a direct oral anticoagulant (DOAC) be used over warfarin for treatment of VTE. In 2020, the American Society of Hematology (ASH), concurred, suggesting DOACs over warfarin.
DOAC dosing in 3 phases of VTE treatment. Dosing of the 3 most commonly used DOACs differs and Dr Moll points out it is important to understand how long to treat at a given dose before titrating down; that period of time will be different with each agent. "Treat as long as needed but not longer than necessary."
How long to continue anticoagulation? The schematic above reflects Dr Moll's "Risk of Recurrence Triangle," which he notes is based on the American College of Chest Physician's 2012 guideline on antithrombotic therapy for VTE disease.
Dr Moll also notes that it is in the intermediate risk population that he obtains a thrombophilia workup and D-dimer while on anticoagulation to help determine whether to continue or discontinue anticoagulation.
Duration of anticoagulation: find the balance. First determine the risk of recurrent VTE; then assess the risk for bleeding; and absolutely talk to the patient about preferences - Dr Moll's "Warfarin" or "DOAC Hate Factor." A hate factor of 0 means: “I don’t mind at all being on this drug. It’s just a pill I have to take.” A value of 10 means: “I hate this drug so much, I absolutely want to come off. I am not worried about another clot.” Gauging the hate factor often opens a discussion about what is really bothering the patient about the drug - and sometimes that is the cost.
Anticoagulation for unusual clots-Dr Moll’s take-home points: Consider DOACs, but data are limited, even for warfarin. Ask the same questions about the event (provoked or not); potential for recurrence; bleeding risk (issue of reversal agents) and balance the decision.
Which DOAC to use when in persons with obesity- Dr Moll's take-home points: Up to BMI 40 kg/m2 and weight 120 kg: all DOACs reasonable. BMI > 40 kg/m2 and > 120 kg: rivaroxaban and apixaban (fewer data) are reasonable.
Oral anticoagulant use post-bariatric surgery-Dr Moll's take-home points. In acute post-operative phase: parenteral anticoagulant. After≥4 wks, switch to warfarin or DOAC may be considered. If DOAC: use trough-level testing to ensure level is in range expected in non-bariatric surgical patient. Additional research necessary on individual agents.
DOACS in patients with renal impairment-Dr Moll's take-home points. Renal impairment/ hemodialysis: Apixaban ok; preferably NOT rivaroxaban (caveat: dosing!) Dosing: 5 mg bid in the heavier, younger, lower risk bleeding person. 2.5 mg bid in the low-weight, elderly, those with comorbidities, those with higher risk for bleeding
DOACs and VTE inpatients treated for cancer-Dr Moll's take-home points. DOACs are good treatment option for patients with cancer and VTE. Apixaban as effective and safe as LMWH. Rivaroxaban (and edoxaban) more effective than LMWH, but more bleeding.
See studies for trials above:
DOACs in antiphospholipid syndrome.
See studies for trials above:
International Society on Thrombosis and Haemostasis: APS. “We recommend that for the treatment of thrombotic APS among patient with any of the following (termed ‘high-risk’ APS patients) that VKA should be used instead of DOACS:
•Triplepositivity •Arterial thrombosis •Small vesselthrombosis or organ involvement •Heart valve disease according to Sydney criteria
DOACs in antiphospholipid syndrome-Dr Moll's take-home points. “In general, I prefer warfarin.” If a patient with APS is doing well on a DOAC (x 2 yrs) – don’t switch to warfarin. In the de novo diagnosed APS patient: unclear what is the best anticoagulant. When “warfarin-hate factor” is high: Dabigatran an option? LMWH? Fondaparinux?
Perioperative management of DOACs: 2019 PAUSE trial supports simple protocol.
PAUSE study conclusion on perioperative management of DOACs.
"...a simple standardized perioperative management strategy without heparin bridging or measurement of coagulation function..."
Perioperative management of DOACs-Dr Moll's take-home points. Minor bleeding risk: Nothing for 1 day before procedure and on day of procedure. Major bleeding risk: Nothing for 2 days before procedure and on day of procedure. Dabigatran: Look at creatinine. Bridging with LMWH is NEVER needed when interrupting a DOAC.
Stephan Moll, MD is Professor of Medicine in the Department of Medicine, Division of Hematology, at the University of North Carolina School of Medicine, in Chapel Hill, NC.