A 74-year-old white man has been hospitalized for the past 11 days for a heart failure exacerbation (height 65 inches, weight 98 kg, BMI 36 kg/m2). He presented with lower extremity edema and shortness of breath, which has since resolved following aggressive diuresis. His past medical history includes hypertension, type 2 diabetes mellitus, history of transient ischemic attack, history of venous thromboembolism (VTE) following a hospitalization 2 years ago. Current inpatient medications include: atorvastatin 80 mg PO daily, sacubitril/valsartan 24/26 mg PO BID, carvedilol 12.5 PO BID, spironolactone 25 mg PO daily, torsemide 40 mg PO daily, dapagliflozin 10 mg PO daily, metformin 1000 mg PO BID, enoxaparin 40 mg SubQ daily, and aspirin 81 mg PO daily.
Labs upon presentation to the emergency department included:
Which agent could be considered to reduce the risk of VTE following hospitalization for this patient?
Show Answer
The correct answer is: B. Rivaroxaban 10 mg PO daily.
Rivaroxaban, a Factor Xa inhibitor, demonstrated a reduction in the occurrence of venous thromboembolism (VTE) in acutely ill medical patients following hospital discharge in the Multicenter, Randomized, Parallel Group Efficacy and Safety Study for the Prevention of Venous Thromboembolism in Hospitalized Acutely Ill Medical Patients Comparing Rivaroxaban with Enoxaparin (MAGELLAN) trial. With this reduction in events came an increased risk of bleeding, including clinically relevant and major bleeding.1 Rivaroxaban has an FDA-indication for VTE prophylaxis in acutely ill medical patients at risk for thromboembolic complications who are not at high risk of bleeding. In the Apixaban Dosing to Optimize Protection from Thrombosis (ADOPT) trial, extending thromboprophylaxis with apixaban 2.5 mg BID was not superior to short-course enoxaparin, and was associated with more bleeding.2 The Extended Prophylaxis for Venous ThromboEmbolism in Acutely Ill Medical Patients With Prolonged Immobilization (EXCLAIM) trial examined the use of enoxaparin versus placebo in patients and extended treatment was associated with a reduction in VTE occurrence, with an increased risk of bleeding.
Extended-duration thromboprophylaxis (EDT) is defined as prophylaxis continuing beyond the hospital course and up to 35 days. This practice is well established in the orthopedic surgery population, but is less common in the acutely ill medical patient. However, this population may have risk factors for venous thromboembolism (VTE) that persist after discharge from the hospital. The majority of VTEs are diagnosed in the outpatient setting, frequently in patients who have been hospitalized in the past 30 days and may have received inadequate inpatient VTE prophylaxis.5 It is important to balance bleeding and thrombosis risk when considering EDT. Current American Society of Hematology Clinical Practice Guidelines recommend against the routine use of EDT based on the moderate impact compared to in-hospital prophylaxis alone.6 The use of EDT should be individualized based on a patient's risk for thromboembolism and risk of bleeding. Specific criteria to reduce the risk of major bleeding in patients receiving rivaroxaban for EDT include active gastroduodenal ulcer, recent bleeding, active cancer, history of severe bronchiectasis or pulmonary cavitation, and dual antiplatelet therapy.
This patient's risk for VTE can be estimated by calculating the IMPROVE Risk Score for VTE (calculated at 5), which estimates his 3-month risk at 7.2%.7 He has no previous history of bleeding however, with an IMPROVE Bleeding Score8 of less than 7 at 2.5 indicating he is not at an increased risk of bleeding.
Drs. Geoffrey Barnes, MD, MSc, FACC and Stanislav Henkin, MD, FACC served as peer reviewers for this patient case.
Supported by an educational grant from Janssen Pharmaceuticals, Inc., administered by Janssen Scientific Affairs, LLC.
To visit the Online Course page for the Practical Management of VTE: Simplifying Anticoagulation Strategies Grant, click here!
References
Cohen AT, Spiro TE, Buller HR, et al. Rivaroxaban for thromboprophylaxis in acutely ill medical patients. N Engl J Med 2013;368:513-23.
Goldhaber SZ, Leizorovicz A, Kakkar AK, et al. Apixaban versus enoxaparin for thromboprophylaxis in medically ill patients. N Engl J Med 2011;365:2167-77.
Hull RD, Schellong SM, Tapson VF, et al. Extended-duration venous thromboembolism prophylaxis in acutely ill medical patients with recently reduced mobility. Ann Intern Med 2010;153:8-18.
Turpie AGG, Hull RD, Schellong SM, et al. Venous thromboembolism risk in ischemic stroke patients receiving extended-duration enoxaparin prophylaxis: results from the EXCLAIM study. Stroke 2013;44:249-51.
Spencer FA, Lessard D, Emery C, Reed G, Goldberg RJ. Venous thromboembolism in the outpatient setting. Arch Intern Med 2007;167:1471-5.
Schünemann HJ, Cushman M, Burnett AE, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv 2018;2:3198-225.
Spyropoulos AC, Anderson FA Jr, FitzGerald G, et al. Predictive and associative models to identify hospitalized medical patients at risk for VTE. Chest 2011;140:706-14.
Rosenberg DJ, Press A, et al. External validation of the IMPROVE Bleeding Risk Assessment Model in medical patients. Thromb Haemost 2016;116:530-6.
Log in to MyACC
