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Who needs extended anticoagulation?

The risk of VTE recurrence after cessation of anticoagulant varies according to primary (provoking) cause. In addition, several secondary risk factors (e.g., proximal vs. distal location and male vs. female sex) contribute to the risk, as shown.1

Primary (provoking) and secondary factors act as modifiers of VTE recurrence risk1

recurrence risk

* Some NOACs, including apixaban, are not currently recommended in patients with active cancer and should not be offered for VTE prophylaxis in this patient population.3 Refer to the SmPC of each NOAC for guidance on use in patients with active cancer.
† NOACs, including apixaban, are not recommended for patients with a history of thrombosis who are diagnosed with antiphospholipid syndrome. In particular for patients that are triple positive (for lupus anticoagulant, anticardiolipin antibodies, and anti-beta-2-glycoprotein I antibodies), treatment with NOACs could be associated with increased rates of recurrent thrombotic events compared with VKA therapy.

[References for image: 1. Kearon C & Akl EA. Blood 2014; 123: 1794–1802. 3. NICE clinical guideline (NG89) March 2018.]

Of note, VTE recurrence is markedly higher in those with unprovoked (i.e., idiopathic) VTE than those with provoked VTE (i.e., VTE associated with a transient major clinical risk factor). A UK study including 35,373 first VTE events revealed 28.4% of those with unprovoked VTE had a risk of a recurrent event within 10 years, compared with 20.5% of those with provoked VTE.2

VTE recurrence is higher in unprovoked VTE 2

Adapted from Martinez et al., 2014.
* E.g. surgery, trauma, significant immobility (bedbound, unable to walk unaided or likely to spend a substantial proportion of day in bed or in a chair), pregnancy or puerperium.
† Oral contraceptive or hormone replacement therapy.

[References for image: 2. Martinez C et al. Thromb Haem 2014; 112: 255‒263. 3. NICE clinical guideline (NG89) March 2018.]






In Preventing recurrence: Preventing recurrence | | How do I identify patients for extended anticoagulation?

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Abbreviations

CPRD = Clinical Practice Research Datalink DVT = Deep Vein Thrombosis NOAC = Non-vitamin K antagonist Oral Anticoagulant OAC = Oral Anticoagulant PE = Pulmonary Embolism VTE = Venous Thromboembolism

References
  1. Kearon C & Akl AE. Blood 2014; 123: 1794–1801.
  2. Martinez C et al. Thromb Haem 2014; 112: 255‒263.
  3. NICE clinical guideline (NG89). Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. August 2019. Available at: https://www.nice.org.uk/guidance/ng89. Last accessed August 2019.

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Job code: 432UK1900506-01
Date of preparation: September 2019

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