How do I identify patients for extended anticoagulation?
Patients with VTE (without cancer) who are receiving an anticoagulant should have a review within 3 months to discuss the risks and benefits of continuing anticoagulation therapy.1 Patients may have had their treatment initiated while in hospital but may be discharged from secondary care before their treatment is complete. GPs therefore play an important role in the long-term management of patients with VTE.
As shown below, the key primary estimator of recurrence in patients with VTE who stop anticoagulation is unprovoked VTE. Such patients have approximately 10% and 30% risk of experiencing a recurrent VTE event at 1 and 5 years, respectively.2
Recent research shows that recurrence rates in patients with VTE provoked by minor persistent or minor transient risk factors are equivalent to those with unprovoked VTE. Therefore, such patients may also benefit from extended anticoagulation therapy.3
Predicting the risk of VTE recurrence if anticoagulation stopped2
[References for image: 2. Kearon C & Akl AE. Blood 2014; 123: 1794–1802.]
Selecting patients for extended anticoagulation requires careful risk-benefit assessment taking into consideration the risk of VTE recurrence vs. the risk of major bleeding in individual patients.2
Determining the duration of extended anticoagulation
A short duration of treatment (at least 3 months) should be based on transient risk factors (e.g., recent surgery, trauma, or immobilisation). The duration of overall therapy should be individualised after careful assessment of the treatment benefit against the risk for bleeding.4
Adapted from Kearon et al. 2014.2 Please note this resource is an author’s article and not a formal guideline.
Assessment tools available to help assess the risk factors include DASH, HERDOO2 and the Vienna prediction model. Please note that the BMS / Pfizer Alliance are not responsible for the accuracy of these assessment tools.
- DASH: D-Dimer, Age, Sex, Hormones
- HERDOO2: Hyperpigmentation, Edema, or Redness in either leg; D-dimer level ≥250 μg/L; Obesity with body mass index ≥30; or Older age, ≥65 years
- Vienna: age, sex, location of VTE, body mass index, factor V Leiden, prothrombin G20210A mutation, D-dimer, and in vitro thrombin generation
The decision to stop or continue anticoagulation should always include patient involvement.5 As described by NICE quality standards for patient experience, patients should be supported by healthcare professionals to understand relevant treatment options, including benefits, risks and potential consequences, and be actively involved in shared decision-making.6
A selection of patient materials are available to download here.
Click here to view ELIQUIS prescribing and adverse event reporting information.
DVT = Deep Vein Thrombosis NICE = National Institute for Health and Care Excellence PE = Pulmonary Embolism VTE = Venous Thromboembolism
- NICE. Quality Standard [QS29]. Venous thromboembolism in adults: diagnosis and management. Available at: https://www.nice.org.uk/guidance/qs29/chapter/List-of-quality-statements. Accessed August 2019.
- Kearon C & Akl AE. Blood 2014; 123: 1794–1801.
- Prins MH et al. Blood Adv 2018; 2: 788–796.
- NICE. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (CG144). November 2015. Available at: www.nice.org.uk/guidance/cg144. Accessed August 2019.
- NICE. Diagnosing venous thromboembolism in primary, secondary and tertiary care (NICE Pathways). Available at: https://pathways.nice.org.uk/pathways/venous-thromboembolism/diagnosing-venous-thromboembolism-in-primary-secondary-and-tertiary-care. Accessed August 2019.
- NICE Quality Standard [QS15]. Patient experience in adult NHS services. Available at: www.nice.org.uk/guidance/qs15/chapter/Quality-statements. Accessed August 2019.
Job code: 432UK1900506-01
Date of preparation: September 2019