Recent changes in thromboembolism treatment

James Douketis, MD, is a professor of medicine at McMaster University and staff physician in general internal medicine and clinical thromboembolism at St. Joseph’s Healthcare Hamilton. He is the immediate past president of Thrombosis Canada.

What has changed in thromboembolism treatment over the recent past?

James Douketis, MD: The recent few years have witnessed a change in how we manage patients who require an anticoagulant. Specifically, what we’ve learned is that the newer anticoagulants, direct oral anticoagulants (DOACs), can be used in an expanding number of patients, and these include patients who have thrombosis at unusual sites like in the brain, cerebral sinus vein thrombosis; in the upper extremity, upper extremity thrombosis; in the abdomen, splanchnic vein thrombosis; and superficial vein thrombosis.

But we’ve also learned that there are situations where we should not be using a DOAC, where we should be using a vitamin K antagonist like warfarin or acenocumarol. What are these situations? The first is in patients with mechanical heart valves. Even if they have the newer-generation mechanical heart valves, the On-X valves, which are thought to be less prothrombotic, we still use a vitamin K antagonist. The second situation is in patients who have rheumatic heart disease and may have atrial fibrillation or another indication for anticoagulation. Once again, vitamin K antagonists are superior to the DOACs.

The other situations are less common but important to know, and these are patients who have antiphospholipid syndrome (APS)—they should be on a vitamin K antagonist; patients who have a left ventricular assist device; and of course patients who are pregnant or who are breastfeeding—in all those situations, we should avoid the use of a DOAC.