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Management of venous thromboembolism in patients experiencing direct oral anticoagulant treatment failure: a single-center review of practice and outcomes

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Abstract

Direct oral anticoagulants (DOACs) have gained in popularity over vitamin K antagonists for the treatment of venous thromboembolism, however their efficacy is not routinely monitored. It is therefore a clinical challenge to know how to respond when treatment with DOACs fails, and there is little formal guidance on how to manage these patients. We sought to characterize VTE patients who experienced DOAC failure at our institution, and rationalize subsequent treatment strategies. We collated the details of 54 consecutive patients with suboptimal response or breakthrough thrombosis on a DOAC, from our large specialist-led thrombosis clinic. Initial treatment changes were recorded, as well as long-term anticoagulation therapy and treatment outcomes. On first recognition of DOAC failure, 69% of patients were temporarily switched to therapeutic-dose low molecular weight heparin; most of the remaining patients were treated with an alternative DOAC regimen. After a limited period of parenteral treatment, 84% of patients returned to oral anticoagulation, the majority of whom experienced no further treatment failures. By the end of follow-up, 72% of patients were either on long-term DOAC therapy or had completed treatment altogether. In the absence of evidence or guidelines, brief rescue of anticoagulation with parenteral therapy can be an effective strategy when treatment with a DOAC fails.

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Acknowledgements

CK has received honoraria and participated in advisory boards for Bristol-Myers Squibb, Pfizer, Bayer, Daiichi Sankyo, Sanofi and Boehringer Ingelheim. NS has received honoraria from Bristol-Myers Squibb.

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Authors and Affiliations

  1. Department of Haematology, Birmingham Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Bordesley Green East, Birmingham, B9 5SS, UK

    Graham McIlroy, Neil Smith, Anand Lokare, Karen Beale & Charalampos Kartsios

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  1. Graham McIlroy
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  2. Neil Smith
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  3. Anand Lokare
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  4. Karen Beale
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  5. Charalampos Kartsios
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Contributions

GM and CK collated the patient data; GM performed the data analyses; all authors collected the data, contributed to the care of the patients, and to the concept of the study; all were involved in writing the manuscript; all approved the final version.

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Correspondence to Graham McIlroy.

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GM, AL, KB report no conflict of interest.

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McIlroy, G., Smith, N., Lokare, A. et al. Management of venous thromboembolism in patients experiencing direct oral anticoagulant treatment failure: a single-center review of practice and outcomes. J Thromb Thrombolysis 49, 441–445 (2020). https://doi.org/10.1007/s11239-020-02042-6

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  • DOI: https://doi.org/10.1007/s11239-020-02042-6

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