Treatment of upper extremity deep vein thrombosis with apixaban and rivaroxaban

Abstract

Randomized controlled trials leading to the approval of apixaban and rivaroxaban for venous thromboembolism (VTE) did not include patients with upper extremity deep vein thrombosis (UE‐DVT). We sought to evaluate the safety and effectiveness of rivaroxaban and apixaban for the treatment of acute UE‐DVT. Consecutive patients with VTE enrolled into the Mayo Clinic VTE Registry, between March 1, 2013 and December 31, 2019, were followed prospectively. Clinical, demographic and imaging data were collected at the time of study recruitment. Patients with a diagnosis of acute UE‐DVT who received rivaroxaban, apixaban, LMWH or warfarin were included. Recurrent VTE, major bleeding, clinical‐relevant non‐major bleeding (CRNMB), and death were assessed at 3‐month intervals. During the study period, 210 patients with acute UE‐DVT were included; 63 were treated with apixaban, 39 with rivaroxaban, and 108 with LWMH and/or warfarin. Overall 51% had catheter‐associated UE‐DVT, 60% had a diagnosis of malignancy, and 14% had concurrent pulmonary embolism. Malignancy was more common in patients treated with LMWH/warfarin (67% vs 52%, P = .03). At 3 months of follow up, one (0.9%) recurrent VTE occurred in a patient treated with LMWH/warfarin and one (1.0%) patient treated with apixaban or rivaroxaban (P = .97). Major bleeding occurred in three patients treated with LMWH/warfarin, and in none of those treated with apixaban or rivaroxaban (P = .09). Clinical‐relevant non‐major bleeding occurred in one patient (0.9%) treated with LWMH/warfarin and two patients (2.0%) treated with apixaban or rivaroxaban (P = .53). Treatment of UE‐DVT with apixaban or rivaroxaban appears to be as safe and effective as LMWH/warfarin.

Editor's Choice – European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

“…293 A more recent case control study comparing apixaban (n ¼ 63) or rivaroxaban (n ¼ 39) with LMWH and/or warfarin (n ¼ 108) concluded that DOACs appeared to be as safe and effective as LMWH and/or warfarin. 294 For patients with cancer associated UEDVT, long term LMWH monotherapy is preferred over the administration of VKAs. Anticoagulation therapy should be continued as long as the cancer remains active if the thrombotic event was not related to a CVC.…”

Diagnostic and Therapeutic Management of Upper Extremity Deep Vein Thrombosis

“…For example, there was an increased risk of thromboembolic and bleeding complications in patients with a mechanical heart valve treated with dabigatran in the RE-ALIGN study [ 45 ]. Data on direct oral anticoagulants (DOACs) for the treatment of UEDVT are very scarce, and include only small studies that mainly evaluated rivaroxaban ( Table 2 ) [ 17 , 46 , 47 , 48 , 49 , 50 ]. Nonetheless, since DOACs are recommended for patients with DVT of the lower extremities, these agents are increasingly being prescribed in patients with UEDVT [ 51 , 52 , 53 ].…”

“…In patients treated with LMWH or warfarin, there was one patient (0.9%) with recurrent thrombosis, three patients (2.8%) with major bleeding, and one patient (0.9%) with clinically relevant non-major bleeding. It is unclear how many patients were treated with apixaban or rivaroxaban [ 50 ]. Four studies evaluated rivaroxaban for UEDVT.…”

A review of upper extremity deep vein thrombosis

“…apixaban, rivaroxaban, and edoxaban in malignancy-associated VTE; some physicians have used these data to argue use of DOACs in malignancy-associated UEDVT [44][45][46][47]. Direct data behind efficacy and safety of DOACs in UEDVT have been limited to very small studies [48][49][50][51][52]. Mechanistically, there is a question as to whether DOACs can appropriately treat foreign body-related thromboses e.g.…”