We asked, and you answered! Here are the responses from this month’s “You Make the Call” question on the duration of anticoagulation in a patient with a history of bilateral pulmonary embolism and a later episode of deep vein thrombosis.
Disclaimer: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is solely at your own risk.
The PE that occurred in the setting of the OCP would be a true provoked event. As such, I would not use long-term anticoagulation and would cease anticoagulation after six months and after the OCP had been stopped for at least six weeks with an alternative effective contraception, such as a levonorgestrel-containing intrauterine device, in place.
The subsequent event was described as a “calf DVT.” The site is not specified more clearly, but I assume this is a below-the-knee DVT. This was preceded by a long car trip and could be considered provoked. One caveat to this is emerging data suggesting that long travel may not be a truly reversible risk factor, as patients with VTE after long-haul flights have a VTE recurrence rate similar to that of patients with unprovoked VTE.
Despite this, I would not commit to lifelong anticoagulation for a below-the-knee DVT but would consider there is an increased risk of VTE and suggest hypervigilance for recurrent DVT and prophylaxis for long-haul flights or periods of prolonged immobilization. If there were no contraindications, I would suggest apixaban 5 mg twice daily (if normal renal function) to commence 48 hours before travel and continue for 48 hours post, with nuanced adjustment depending on the travel schedule.
John Hounsell, MBBS
Melbourne, Australia
With such a severe history, the first thing to do is to assess whether we can identify the cause. It is true she took the pill, and it is true she had a long car ride, so one might say the episodes were “provoked,” but the provocation was modest. Therefore, if not already done, in my view the patient ought to have a full thrombophilia screen, including protein S, protein C, the common prothrombin mutation, factor V Leiden, MTHFR, etc. In addition, we don’t know her blood counts, but with recurrent thrombosis we should rule out paroxysmal nocturnal hemoglobinuria.
Lucio Luzzatto, MD
Florence, Italy
Bilateral PE is a cause of concern. As the American Society of Hematology guidelines suggest, I would do thrombophilia testing. If positive, I would certainly put the patient on indefinite anticoagulation after the next DVT — wherever the thrombus was — particularly since a car ride is a mild provocation. If negative (and the family and pregnancy history is negative), I would take her off anticoagulation after the three months, only if she desired it (shared decision-making). I would then get a D-dimer after one month off (I know — please don’t throw tomatoes at me), and if negative, I might sleep better at night.
If the first event were not a bilateral PE but a lower extremity DVT, I would be less worried. Maybe.
Henny Billett, MD
Bronx, NY
For patients with a clear-cut history of provoked DVT, when the provoking event cannot be avoided, I generally use injectables (enoxaparin or fondaparinux) prior to the event rather than direct oral anticoagulants.
Mark Robbins, MD
Sun City Center, FL
I would recommend anticoagulation for one year.
Tiziano Barbui, MD
Bergamo, Italy
This recurrent, provoked VTE is associated with a minor transient risk factor (such as a long flight or car ride). Therefore, I would consider indefinite anticoagulation, provided the bleeding risk is not high. For recurrent, unprovoked DVT, I would continue treatment indefinitely if it is evident that the patient experienced two separate unprovoked distal DVT incidents, so long as the risk of bleeding is not high.
Israr Khan, MD
Chicago, IL
I would investigate for antiphospholipid antibody syndrome. For below-the-knee DVT, I recommend anticoagulation for six months. I don’t think I would prescribe apixaban prophylaxis.
Ambar Garg, MBBS, DM
Raipur, India
In the first episode, I would use anticoagulation for six months because she has a severe thrombosis (bilateral PE) manifestation. In the case of recurrence, I agree with a duration of three months, provided she has recanalization in the deep veins and low levels of D-dimers. After that, follow-up should include serial D-dimer tests every three months, along with recommendations for prophylaxis in high-risk situations (flying and long car rides) using apixaban 5 mg or enoxaparin.
Hegta Rodrigues Figueiroa, MD
São Paulo, Brazil
