Treatment of Venous Thromboembolism in Elite Athletes: A Suggested Approach to Individualized Anticoagulation

Abstract

Venous thromboembolism (VTE) is a leading cause of morbidity with potentially detrimental career consequences in elite athletes. Their unique predisposing factors entail a higher-than-expected VTE incidence. Anticoagulation treatment is challenging, especially among those athletes wishing to resume their competitive activities. The authors review the current VTE treatment guidelines from the perspective of treating elite athletes. They then provide an expert opinion individualized treatment approach based on the pharmacokinetic properties of direct oral anticoagulants that permits tailoring the drug's timing to the athlete's competitive endeavors. They also present low-molecular-weight heparin as an alternative. The proposed risk management approach allows mitigation against VTE recurrence, reducing the chance of major bleeding, and honoring the athlete's self-determination to resume their career while accepting the risks involved. A shared decision making with the athlete and his/her team along with the presence of adequate resources are key components. Ultimately, the authors hope this work will serve as a stepping stone to validated VTE treatment regimens that consider the particularities of elite athletes.

Diagnosis, Management of, and Return to Play Guidance for Venous Thromboembolism in Athletes

“…Management of VTE in athletes (10). Adapted considering the intermittent dosing strategies proposed by Moll et al and Nazha et al (23,24). …”

Venous thromboemboli associated with acute aerobic exercise: A review of case report commonalities

“…Collectively these findings support that proper development of evidence‐based RTP guidelines will further facilitate the successful resumption of exercise participation and competition. Indeed, new anticoagulation guidelines suggest intermittent anticoagulation could be the key to managing elite or contact athletes who wish to return to competition as soon as possible. However, there are no comprehensive RTP guidelines which could be used for recreationally active individuals and non‐elite athletes, an especially critical knowledge gap given these individuals may not have access to expert clinical oversight for developing a plan to safely resume physical activity.…”

Recommendations from the ICM-VTE: Sports

“…Nahza et al, recommended an individualized approach to DOAC prescribing in high-risk patients after return to non-contact sport, which was analogous to the periprocedural management of DOAC use in the general population. This approach consists of limiting DOAC use in the days leading up to sporting events with the aim of ensuring low physiologic levels of anticoagulant use when an athlete is competing, and then returning to higher levels of DOAC use outside of competition 133,135,136 . Although there is no consensus recommending one DOAC over another, one study showed that apixaban had shorter thrombin inhibition compared to rivaroxaban.…”

“…The most common treatment described involves initiating LMWH or unfractionated heparin, followed by a vitamin K antagonist such as warfarin until a target International Normalized Ratio (INR) of 2.0 – 3.0 is reached 125 . DOAC such as rivaroxaban or apixaban may be preferred due to greater convenience and shorter half-lives that offer the possibility of intermittent dosing during sport participation 133 . Nahza et al, recommended an individualized approach to DOAC prescribing in high-risk patients after return to non-contact sport, which was analogous to the periprocedural management of DOAC use in the general population.…”