Recent changes in antithrombotic therapy

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’s new in antithrombotic therapy? What should we know to stay up to date?

James Douketis, MD: In addition to what we’ve just discussed about situations where you can and cannot use a direct oral anticoagulant (DOAC), there are new treatments that are being developed, and these are oral agents and sometimes injectable agents that act to inhibit factor XI. So, this is a little bit higher upstream in the coagulation cascade. It is possible that they will be used more and more, but we have to await the results of clinical trials to demonstrate that they are as effective. They are thought to be safer than the existing anticoagulants, so hopefully that will be the case. But we have to await the results of ongoing trials.

The other area that I think we should be aware of is how we use thrombolytic therapy, so, the more aggressive type of antithrombotic therapy. There are ongoing studies in patients with pulmonary embolism, for example, where we’re using a lower dose of the thrombolytic therapy to see if it can be as effective to shrink or reduce the clot in the lungs, but also it can be safer for patients.

And we are also looking at treatments that are used in combination with thrombolytic therapy. What I mean is mechanical methods to remove the clot, or methods to extract the clot from the leg or from the lungs. There are also treatments such as stents that can be placed in the lower extremities and the veins. This is an area where the evidence is still a little bit hazy, so we have to just also await the results of trials, but [the answer would be] (1) new ways to use thrombolytic therapy, (2) mechanical devices to extract clots from the lungs or the legs, and (3) in some cases, the use of venous stents.