Clinical studyExtended outpatient therapy with low molecular weight heparin for the treatment of recurrent venous thromboembolism despite warfarin therapy
Section snippets
Patients and eligibility
All patients with recurrent symptomatic venous thromboembolism while being treated with warfarin were identified by a review of the prospective databases of three tertiary care thrombosis clinics (London Health Sciences Center, Ottawa Civic Hospital, and Queen Elizabeth II Health Sciences Center) from June 1996 to August 1998. To be eligible for this series, patients must have had objectively documented deep vein thrombosis or pulmonary embolism. The initial event must have been treated with
Results
Symptomatic recurrent venous thromboembolism developed in 32 patients while on a warfarin regimen. The average age of patients was 56 years (range, 17 to 85, SD = 17). Fifteen (47%) were men. At the time of initial presentation, 27 patients (84%) had deep vein thrombosis, 4 (13%) had pulmonary embolism, and 1 (3%) had both. Four patients (13%) had episodes of venous thromboembolism prior to the index case (Table). Twenty (63%) patients had cancer (15 cases were metastatic), 9 (13%) were
Discussion
Recurrence of venous thromboembolism in patients while taking warfarin was first reported among cancer patients 7, 8. Recent studies have reported that symptomatic venous thromboembolism recurs in approximately 5% of patients despite adequate oral anticoagulation 1, 2. Malignancy is a well-known risk factor for venous thromboembolism and is associated with a significantly higher frequency of recurrent events (9% vs. 1% with no malignancy) at 3 months 1, 2, 9. Other conditions associated with
References (15)
- et al.
Managing oral anticoagulant therapy
Chest
(2001) - et al.
The long-term clinical course of acute deep venous thrombosis
Ann Intern Med
(1996) Low molecular weight heparin in the treatment of patients with venous thromboembolism
N Engl J Med
(1997)- et al.
A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis
N Engl J Med
(1996) - et al.
Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home
N Engl J Med
(1996) - et al.
Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low-molecular-weight heparinA comparison of patient self-injection to home care injection
Arch Intern Med
(1998) - et al.
A comparison of three months of anticoagulation with extended anticoagulation for a first episode of idiopathic venous thromboembolism
N Engl J Med
(1999)
Cited by (75)
Rivaroxaban plus aspirin versus acenocoumarol to manage recurrent venous thromboembolic events despite systemic anticoagulation with rivaroxaban
2023, Thrombosis ResearchCitation Excerpt :Recurrent DVT despite anticoagulation has been related to active cancer, subtherapeutic anticoagulation, use of concomitant anticancer drugs, younger age at presentation (<65 years), and PE as the initial DVT [31–37]. It has been suggested that increasing the dose of low-molecular-weight heparin (LMWH) may be an alternative in patients with recurrent DVT [38–45]; however, to date, there has been no systematic review or randomized trial focused on the treatment of patients with recurrent DVT and PE during anticoagulant therapy. The combination of rivaroxaban plus aspirin has been previously explored in patients with increased risk of atherothrombotic and venous thromboembolic events.
Treatment of venous thromboembolism in cancer patients: The dark side of the moon
2021, Cancer Treatment ReviewsCitation Excerpt :The proportion of patients with recurrent VTE during treatment with factor Xa inhibitors was lower, but still relevant with an overall pooled incidence of about 6% [3]. Evidence to guide treatment of recurrent VTE in cancer patients is weak and largely based on few retrospective studies [87–90]. In a cohort of 70 cancer patients with recurrent VTE, patients who recurred on VKAs or sub-therapeutic dose LMWH received full-dose LMWH for 4–12 weeks, while those who developed recurrent VTE despite full-dose LMWH were treated according to a dose-escalating approach by increasing the dose of about 25% for at least 4 weeks [88].
Prevention, Diagnosis, and Treatment of VTE in Patients With Coronavirus Disease 2019: CHEST Guideline and Expert Panel Report
2020, ChestCitation Excerpt :There are no studies assessing the treatment of recurrent VTE despite anticoagulation with DOACs. One retrospective study reported reasonable outcomes (recurrent VTE of 9% [95% CI, 2 to 25]) when using therapeutic weight-adjusted LMWH in patients with recurrent VTE despite oral anticoagulation with vitamin K antagonists.66 Two small retrospective cohort studies have also reported reasonable outcome by increasing the dose of LMWH to 125% and 130% in patients with recurrent events despite therapeutic weight-adjusted LMWH.67,68
Management of suspected and confirmed recurrent venous thrombosis while on anticoagulant therapy. What next?
2019, Thrombosis ResearchCitation Excerpt :There are, however, compelling retrospective cohort studies that collectively provide some evidence, albeit weak, upon which to guide practice. Luk and colleagues reported a retrospective cohort study of 82 patients who developed recurrent VTE despite VKAs therapy, who were then switched to full-dose dalteparin for at least 4 weeks [29]. The risk of subsequent recurrent VTE was 9% (3/32; (95% CI 2–25%) over an unspecified duration of follow-up in these patients.
Clinical outcomes of venous thromboembolism with dalteparin therapy in multiple myeloma patients
2015, Thrombosis ResearchCitation Excerpt :VTE treatment and second prophylaxis with LMWH may be a more effective and practical alternative to oral anticoagulant therapy. Unlike vitamin K antagonists (VKA), LMWH have predictable pharmacokinetic properties and drug interactions [9], and they can be effective in patients with cancer who have recurrent VTE while receiving warfarin [10,11]. Poor gastrointestinal absorption is not a concern with subcutaneously injected LMWH.
Recurrent venous thromboembolism in anticoagulated patients with cancer: Management and short-term prognosis
2015, Journal of Thrombosis and Haemostasis
- 1
Dr. Michael Kovacs is an Internal Scholar with the Department of Medicine at the University of Western Ontario. Dr. Philip Wells is a Canada Research Chair.