Nichole Brunton, Waldemar E Wysokinski, David O Hodge, Danielle T Vlazny, Robert D McBane, Damon E Houghton, Ana I Casanegra
ROA can affect 3% of patients with VTE. Nearly half of ROA events are preventable with careful review of medications and patient characteristics. When not modifiable, the most used strategy for managing patients with ACF is to transition to another anticoagulant, usually enoxaparin. Our practice strategy for evaluating and managing ROA is outlined.
BACKGROUND: Venous thromboembolism (VTE) recurrence on anticoagulation (ROA) and anticoagulant failure (ACF) are frequently described but poorly defined.
OBJECTIVES: To determine the incidence and causes of ROA and ACF in patients with VTE. The secondary aim was to describe the management of these cases, including anticoagulation selection and dosing strategies.
METHODS: Patients with acute VTE enrolled in the Mayo Clinic VTE Registry from 2013 to 2022 were included. Charts of patients with VTE recurrence despite anticoagulation were reviewed. ROA was defined as any new thrombotic event in patients prescribed and recently taking anticoagulants. ACF was defined as ROA in the absence of modifiable risk factors.
RESULTS: Of the 4980 patients included, 150 (3.0%) ROA events occurred in 130 patients. Altered absorption (n = 40, 26.7%), medication dosing (n = 35, 23.3%), and recent interruption of therapy (n = 37, 24.7%) were frequently documented reasons for ROA events. Malignancy was present in 107 (71.3%) patients, with 47 (43.9%) having metastatic malignancy. ROA was attributed to a modifiable cause in 75 (50.0%) patients. In 26 (17.3%) patients, there were no identifiable reasons for failure, and these were labeled as ACF. After a recurrent VTE event, 92 (61.3%) patients were transitioned to an alternative anticoagulant, with the most frequent being enoxaparin. However, 27 (18.0%) patients remained on the same medication at an increased dose, and 27 (18.0%) did not have any change in therapy. There were 4 (2.7%) patients with unclear management strategies.
CONCLUSION: ROA can affect 3% of patients with VTE. Nearly half of ROA events are preventable with careful review of medications and patient characteristics. When not modifiable, the most used strategy for managing patients with ACF is to transition to another anticoagulant, usually enoxaparin. Our practice strategy for evaluating and managing ROA is outlined.