Optimal Management of Anticoagulation Therapy

Publication Date: November 27, 2018
Last Updated: March 14, 2022

Recommendations

Initial anticoagulant dose selection

In obese patients receiving low-molecular-weight heparin (LMWH) therapy for treatment of acute VTE, the American Society of Hematology (ASH) guideline panel suggests initial LMWH dose selection according to actual body weight rather than dose selection based on a fixed maximum daily dose (ie, capped dose). (2, ⊕ooo)
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Drug-interaction management

For patients requiring administration of inhibitors or inducers of P-glycoprotein (P-gp) or strong inhibitors or inducers of cytochrome P450 (CYP) enzymes, the ASH guideline panel suggests using an alternative anticoagulant (such as vitamin K antagonist [VKA] or LMWH) rather than a direct oral anticoagulant (DOAC) for the treatment of VTE. (2, ⊕ooo)
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Point-of-care INR testing

For patients receiving maintenance VKA therapy for treatment of VTE, the ASH guideline panel suggests using home point-of-care INR testing (patient self-testing [PST]) over any other INR testing approach except patient self-management (PSM) (see recommendation 4) in suitable patients (those who have demonstrated competency to perform PST and who can afford this option). (2, ⊕⊕oo)
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For patients receiving maintenance VKA therapy for treatment of VTE, the ASH guideline panel recommends using point-of-care INR testing by the patient at home and self-adjustment of VKA dose (PSM) over any other management approach, including PST in suitable patients (those who have demonstrated competency to perform PSM and who can afford this option). (1, ⊕⊕oo)
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Selecting the timing between INR measurements (INR recall interval)

For patients receiving VKA therapy for treatment of VTE, the ASH guideline panel suggests using an INR recall interval of 4 weeks or fewer rather than intervals longer than 4 weeks following VKA dose adjustment due to an out-of-target-range INR. (2, ⊕ooo)
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For patients receiving maintenance VKA therapy for treatment of VTE, the ASH guideline panel suggests using a longer (6-12 weeks) INR recall interval rather than a shorter (4 weeks) INR recall interval during periods of stable INR control. (2, ⊕ooo)
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Laboratory monitoring of the anticoagulant response

For patients with renal dysfunction (creatinine clearance, <30 mL/min) receiving LMWH therapy for treatment of VTE, the ASH guideline panel suggests against using anti–factor Xa concentration monitoring to guide LMWH dose adjustment. (2, ⊕ooo)
Remark: Instead of monitoring anti–factor Xa concentrations, providers should consider using doses adjusted for renal function as recommended in product labeling (eg, enoxaparin) or switching to an alternative anticoagulant with lower renal clearance, such as unfractionated heparin (UFH) or a different LMWH.
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For patients with obesity receiving LMWH therapy for treatment of VTE, the ASH guideline panel suggests against using anti–factor Xa concentration monitoring to guide LMWH dose adjustmen. (2, ⊕ooo)
Remark: Providers should consider LMWH using doses based on actual body weight (see recommendation 1) and not monitoring anti–factor Xa concentrations, similar to the approach used in nonobese patients.
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For patients receiving DOAC therapy for the treatment of VTE, the ASH guideline panel suggests against measuring the DOAC anticoagulant effect during management of bleeding. (2, ⊕ooo)
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Transitions between anticoagulants

For patients transitioning from DOAC to VKA, the ASH guideline panel suggests overlapping DOAC and VKA therapy until the INR is within the therapeutic range over using LMWH or UFH “bridging therapy.” (2, ⊕ooo)
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Use of specialized AMSs

For patients receiving anticoagulation therapy for treatment of VTE, the ASH guideline panel suggests using specialized AMS care rather than care provided by the patient’s usual health care provider. (2, ⊕ooo)
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Structured patient education

For patients receiving oral anticoagulation therapy for VTE treatment, the ASH guideline panel suggests using supplementary patient education in addition to basic education. (2, ⊕ooo)
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Efforts to improve anticoagulant-medication adherence

For patients receiving anticoagulation therapy for treatment of VTE, the ASH guideline panel suggests against using a daily lottery (between a 1-in-5 and 1-in-100 chance of a monetary reward each day if a pill compartment on a sophisticated electronic-medication-monitoring system is accessed) to improve medication adherence. (2, ⊕ooo)
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For patients receiving anticoagulation therapy for treatment of VTE, the ASH guideline panel suggests against using electronic reminders (daily alarm via an electronic-medication-monitoring system) to improve medication adherence. (2, ⊕ooo)
Remark: This recommendation applies specifically to a sophisticated alert system used in the study evaluated by the panel.
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For patients receiving anticoagulation therapy for treatment of VTE, the ASH guideline panel recommends against using a daily lottery (see recommendation 13a) plus electronic reminders (see recommendation 13b) to improve medication adherence. (1, ⊕ooo)
Remark: This recommendation applies specifically to a sophisticated alert system used in the study evaluated by the panel.
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For patients receiving anticoagulation therapy for treatment of VTE, the ASH guideline panel suggests against using visual medication schedules (provided to patients at each visit, along with brief counseling) to improve medication adherence. (2, ⊕ooo)
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Invasive procedure management

For patients at low to moderate risk of recurrent VTE who require interruption of VKA therapy for invasive procedures, the ASH guideline panel recommends against periprocedural bridging with LMWH or UHF in favor of interruption of VKA alone. (1, ⊕⊕⊕o)
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For patients interrupting DOAC therapy for scheduled invasive procedures, the ASH guideline panel suggests against performing laboratory testing for DOAC anticoagulant effect prior to procedures. (2, ⊕ooo)
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Excessive anticoagulation and bleeding management

For patients receiving VKA for treatment of VTE with INRs of >4.5 but <10 and without clinically relevant bleeding, the ASH guideline panel suggests using temporary cessation of VKA alone without the addition of vitamin K. (2, ⊕ooo)
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For patients with life-threatening bleeding during VKA treatment of VTE who have an elevated INR, the ASH guideline panel suggests using 4-factor prothrombin complex concentrates (PCCs) rather than fresh-frozen plasma (FFP) as an addition to cessation of VKA and IV vitamin K. (2, ⊕ooo)
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For patients with life-threatening bleeding during oral direct Xa inhibitor treatment of VTE, the ASH guideline panel suggests using either 4-factor PCC administration as an addition to cessation of oral direct Xa inhibitor or cessation of oral direct Xa inhibitor alone. (2, ⊕ooo)

Remark: This recommendation does not apply to non–life-threatening bleeding. No data are available comparing the efficacy of 4-factor PCC and coagulation factor Xa (recombinant), inactivated-zhzo. The guideline panel offers no recommendation for 1 approach over the other.

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For patients with life-threatening bleeding during oral direct Xa inhibitor treatment of VTE, the ASH guideline panel suggests using coagulation factor Xa (recombinant), inactivated-zhzo in addition to cessation of oral direct Xa inhibitor rather than no coagulation factor Xa (recombinant), inactivated-zhzo. (2, ⊕ooo)
Remark: This recommendation does not apply to non–life-threatening bleeding. No data are available comparing the efficacy of 4-factor PCC and coagulation factor Xa (recombinant), inactivated-zhzo. The guideline panel offers no recommendation for 1 approach over the other.
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For patients with life-threatening bleeding during dabigatran treatment of VTE, the ASH guideline panel suggests using idarucizumab in addition to cessation of dabigatran rather than no idarucizumab. (2, ⊕ooo)
Remark: This recommendation does not apply to non–life-threatening bleeding.
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For patients with life-threatening bleeding during LMWH or UFH treatment of VTE, the ASH guideline panel suggests using protamine in addition to cessation of LMWH or UFH rather than no protamine. (2, ⊕ooo)
Remark: This recommendation does not apply to non–life-threatening bleeding.
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Anticoagulant resumption following bleeding

21. For patients receiving anticoagulation therapy for VTE who survive an episode of major bleeding, the ASH guideline panel suggests resumption of oral anticoagulation therapy within 90 days rather than discontinuation of oral anticoagulation therapy. (2, ⊕ooo)
Remark: This recommendation specifically applies to patients who require long-term or indefinite anticoagulation (ie, are at moderate to high risk for recurrent VTE, are not at high risk for recurrent bleeding, and are willing to continue anticoagulation therapy).
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Recommendation Grading

Disclaimer

Overview

Title

Optimal Management of Anticoagulation Therapy

Authoring Organization

Publication Month/Year

November 27, 2018

Last Updated Month/Year

June 9, 2022

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE. These guidelines assume the choice of anticoagulant has already been made.

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Long term care, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D054556 - Venous Thromboembolism, D020246 - Venous Thrombosis, D000925 - Anticoagulants

Keywords

anticoagulation, Venous Thromboembolism, Anticoagulation

Source Citation

Blood Adv (2018) 2 (22): 3257–3291.