Extended oral anticoagulation after incident venous thromboembolism – a paradigm shift?

ABSTRACT

Introduction

Patients with incident venous thromboembolism carry a chronic risk of suffering a recurrent event. Anticoagulation is effective at preventing recurrence during treatment but also associated with risk of bleeding. Hence, the dilemma of optimal anticoagulant treatment duration beyond the acute treatment phase remains a clinical challenge in the management of venous thromboembolism.

Areas covered

This review summarizes the current evidence for extended oral anticoagulant treatment after incident venous thromboembolism, and discusses dilemmas involved in treatment decisions related to extended secondary prevention.

Expert opinion

Results from landmark venous thromboembolism-extended treatment studies focused on direct oral anticoagulants suggest a paradigm shift of the risk–benefit balance in favor of extended anticoagulant treatment. Nevertheless, patient preferences need to be considered while persistent concerns about enduring risk of bleeding must be addressed for the new paradigm to be implemented into clinical practice.

KEYWORDS:

• Venous thromboembolism
• recurrence
• anticoagulation
• extended treatment
• NOAC

Article highlights

• Optimal duration of the extended anticoagulation remains one of the most vexing issues in the venous thromboembolism management.

• For the treating physician, determination of the individual’s risk–benefit profile for extended therapy remains a challenge.

• A relative safety of new oral anticoagulants over vitamin-K antagonists has led to a paradigm-shift suggesting extended, rather than limited, duration anticoagulation regimens for venous thromboembolism.

Declaration of interest

I. Albertsen has received speaking fees from Pfizer and Bayer. G. Piazza has received research grant support from EKOS, a BTG International Group company, Bristol-Myers Squibb, Daiichi-Sankyo, and Janssen. P. Nielsen has received speaking fees from Boehringer Ingelheim and BMS/Pfizer; consulting fees from Bayer and Daiichi-Sankyo; and grant support from BMS/Pfizer and Daiichi-Sankyo. T. Larsen has served as an investigator for Janssen Scientific Affairs, LLC, and Boehringer Ingelheim, and has been on the speaker bureaus for Bayer, BMS/Pfizer, Roche Diagnostics, Boehringer Ingelheim, and Takeda Pharma. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Box 1. Dilemmas and unanswered questions of extended anticoagulant treatment

Table

Additional information

Funding

The Obel Family Foundation partly funded this research by an unrestricted grant. The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; in the writing of the report; and in the decision to submit the paper for publication.