Suggested and discouraged antithrombotic management after recurrence on anticoagulation
| Cause . | Suggested management . | Discouraged management . |
|---|---|---|
| Cancer | Switch to LMWH, perhaps escalate dose of LMWH (see Figure 2) (ACCP Grade 2C)41,42,44 ; for myeloproliferative neoplasm consider cytoreduction, and antiaggregants71 | VKAs or NOACs during the first 3 months |
| Behçet disease | Glucocorticoids, azathioprine, cyclophosphamide, cyclosporine A (all recommended by EULAR58 ); colchicine or infliximab | Anticoagulants alone |
| Antiphospholipid syndrome | If receiving VKAs or a NOAC, switch to LMWH | Monitoring of warfarin with a point-of-care instrument or with a thromboplastin sensitive to lupus anticoagulant14 |
| Paroxysmal nocturnal hemoglobinuria | Anticoagulation and eculizumab18 | Anticoagulation alone |
| Heparin-induced thrombocytopenia | Argatroban, lepirudin, danaparoid (all ACCP Grade 2C),68 fondaparinux72 | Heparin or LMWH |
| Pregnancy | Check anti-Xa level, escalate dose of LMWH or heparin | NOACs contraindicated, VKAs |
| Vascular abnormalities | Endovascular stent, possibly decompression surgery, and higher-intensity anticoagulation73 | |
| NOAC and | ||
| Inappropriate dose | Increase to recommended dose | |
| Body weight >120 kg | Switch to VKA | |
| Use of strong inducer of CYP3A4or of P-gp | Switch to VKA | |
| Rivaroxaban taken without food | Instruct patient to take rivaroxaban with food | |
| Poor adherence | Consider switch to VKA for better supervision |
| Cause . | Suggested management . | Discouraged management . |
|---|---|---|
| Cancer | Switch to LMWH, perhaps escalate dose of LMWH (see Figure 2) (ACCP Grade 2C)41,42,44 ; for myeloproliferative neoplasm consider cytoreduction, and antiaggregants71 | VKAs or NOACs during the first 3 months |
| Behçet disease | Glucocorticoids, azathioprine, cyclophosphamide, cyclosporine A (all recommended by EULAR58 ); colchicine or infliximab | Anticoagulants alone |
| Antiphospholipid syndrome | If receiving VKAs or a NOAC, switch to LMWH | Monitoring of warfarin with a point-of-care instrument or with a thromboplastin sensitive to lupus anticoagulant14 |
| Paroxysmal nocturnal hemoglobinuria | Anticoagulation and eculizumab18 | Anticoagulation alone |
| Heparin-induced thrombocytopenia | Argatroban, lepirudin, danaparoid (all ACCP Grade 2C),68 fondaparinux72 | Heparin or LMWH |
| Pregnancy | Check anti-Xa level, escalate dose of LMWH or heparin | NOACs contraindicated, VKAs |
| Vascular abnormalities | Endovascular stent, possibly decompression surgery, and higher-intensity anticoagulation73 | |
| NOAC and | ||
| Inappropriate dose | Increase to recommended dose | |
| Body weight >120 kg | Switch to VKA | |
| Use of strong inducer of CYP3A4or of P-gp | Switch to VKA | |
| Rivaroxaban taken without food | Instruct patient to take rivaroxaban with food | |
| Poor adherence | Consider switch to VKA for better supervision |