Management of anticoagulant treatment in specific patient categories
| Clinical setting . | Patients subgroups . | Limitations . | Recommended strategies . |
|---|---|---|---|
| Renal function | Stage I-II KDOQI (GFR ≥60) | None | DOACs |
| Stage III KDOQI (GFR 59-30) | Dose reduction not tested in VTE | DOACs | |
| Stage IV KDOQI (GFR 29-15) | Avoid DOACs | VKAs or halved-dose LMWH | |
| Dialysis | Avoid DOACs & LMWH | VKAs | |
| Elderly | Over 75 years | Very limited data available | DOACs |
| Comorbidities & concomitant therapies | Adapt accordingly | ||
| Consider bleeding risk | Consider to avoid thrombolysis | ||
| Polypharmacotherapy | Strong inhibitors/competitors | Potential DOACs overdosing | Consider to avoid DOACs |
| Strong inducers/competitors | Potential DOACs underdosing | Consider to avoid DOACs | |
| Moderate inhibitors/inducers | Consider potential interactions | Consider DOACs at standard dose | |
| Dual antiplatelet | Consider to stop ≥1 antiplatelet | Consider DOACs (with ASA) | |
| Pregnancy & breast-feeding | Pregnancy I trimester | Avoid DOACs & VKAs | LMWH |
| Pregnancy II-III trimesters | Avoid DOACs | LMWH | |
| Breast-feeding | Avoid DOACs & VKAs | LMWH | |
| Cancer | Oral route not feasible | Avoid DOACs | LMWH |
| Gastrointestinal cancer | Avoid DOACs | LMWH (DOACs second choice) | |
| On chemotherapy | Assess for DOACs interactions | Edoxaban/rivaroxaban or LMWH | |
| Isolated Distal DVT | Asymptomatic DVT | Limited data available | Consider US surveillance |
| Cancer or previous VTE | Treat as proximal | LMWH or VKAs (or DOACs) | |
| All symptomatic distal DVT | Limited observational data with DOACs | LMWH or VKAs (or DOACs) | |
| Isolated Subsegmental PE | Asymptomatic incidental PE | Limited data available | Consider clinical surveillance or DOACs |
| Concomitant cancer | Treat as PE | Edoxaban/rivaroxaban or LMWH | |
| Symptomatic PE | Treat as PE | DOACs | |
| Vena cava filter | Absolute contraindications for anticoagulant treatment | Limited data available with DOACs | Start anticoagulant treatment as soon as possible |
| Clinical setting . | Patients subgroups . | Limitations . | Recommended strategies . |
|---|---|---|---|
| Renal function | Stage I-II KDOQI (GFR ≥60) | None | DOACs |
| Stage III KDOQI (GFR 59-30) | Dose reduction not tested in VTE | DOACs | |
| Stage IV KDOQI (GFR 29-15) | Avoid DOACs | VKAs or halved-dose LMWH | |
| Dialysis | Avoid DOACs & LMWH | VKAs | |
| Elderly | Over 75 years | Very limited data available | DOACs |
| Comorbidities & concomitant therapies | Adapt accordingly | ||
| Consider bleeding risk | Consider to avoid thrombolysis | ||
| Polypharmacotherapy | Strong inhibitors/competitors | Potential DOACs overdosing | Consider to avoid DOACs |
| Strong inducers/competitors | Potential DOACs underdosing | Consider to avoid DOACs | |
| Moderate inhibitors/inducers | Consider potential interactions | Consider DOACs at standard dose | |
| Dual antiplatelet | Consider to stop ≥1 antiplatelet | Consider DOACs (with ASA) | |
| Pregnancy & breast-feeding | Pregnancy I trimester | Avoid DOACs & VKAs | LMWH |
| Pregnancy II-III trimesters | Avoid DOACs | LMWH | |
| Breast-feeding | Avoid DOACs & VKAs | LMWH | |
| Cancer | Oral route not feasible | Avoid DOACs | LMWH |
| Gastrointestinal cancer | Avoid DOACs | LMWH (DOACs second choice) | |
| On chemotherapy | Assess for DOACs interactions | Edoxaban/rivaroxaban or LMWH | |
| Isolated Distal DVT | Asymptomatic DVT | Limited data available | Consider US surveillance |
| Cancer or previous VTE | Treat as proximal | LMWH or VKAs (or DOACs) | |
| All symptomatic distal DVT | Limited observational data with DOACs | LMWH or VKAs (or DOACs) | |
| Isolated Subsegmental PE | Asymptomatic incidental PE | Limited data available | Consider clinical surveillance or DOACs |
| Concomitant cancer | Treat as PE | Edoxaban/rivaroxaban or LMWH | |
| Symptomatic PE | Treat as PE | DOACs | |
| Vena cava filter | Absolute contraindications for anticoagulant treatment | Limited data available with DOACs | Start anticoagulant treatment as soon as possible |
ASA, low-dose aspirin; GFR, glomerular filtration rate in mL/min/1.73 m2; KDOQI, Kidney Disease Outcomes Quality Initiative.