Optimal therapeutic management of acute and chronic venous thromboembolism

In recent years, Direct Oral Anticoagulants (DOACs) have largely replaced vitamin-k antagonists as treatment of choice for venous thromboembolism for 3 main reasons. First, DOACs were shown to be associated with less major bleeding than conventional anticoagulants. Second, DOACs have only few interactions with other drugs and food and third, DOACs dot need routine blood measurements to guide optimal dosing but may be prescribed in a fixed either once or twice daily dose. Although the introduction of the DOACs was a major improvement for the prognosis of patients with VTE, several challenges remain. For instance, the optimal treatment of severe acute VTE, e.g. patients with acute pulmonary embolism (PE) associated with right ventricular overload or even shock, is unknown. Also, where guidelines recommend long-term treatment with DOACs after a first unprovoked VTE for all patients but the ones with high bleeding risk, tools to assess the risk of bleeding for these patients are unavailable.

Over the past years, we have been performing cutting edge research to solve several of these challenges. Current active trials involve the HOME study in which to prognostic tools for selecting patients with PE for outpatient treatment, and PEITHO-2 study that evaluated the safety of using clinical criteria to identify the optimal moment to switch from parenteral to oral anticoagulant treatment in patients with intermediate-risk PE.

Three relevant publications of our group (with collaborators) within this theme are:
1. Klok FA, Hösel V, Clemens A, Yollo WD, Tilke C, Schulman S, Lankeit M, Konstantinides SV. Prediction of bleeding events in patients with venous thromboembolism on stable anticoagulation treatment. Eur Respir J 2016;48:1369-1376
2. den Exter PL, Zondag W, Klok FA, Brouwer RE, Dolsma J, Eijsvogel M, Faber LM, van Gerwen M, Grootenboers MJ, Heller-Baan R, Hovens MM, Jonkers GJ, van Kralingen KW, Melissant CF, Peltenburg H, Post JP, van de Ree MA, Vlasveld LT, de Vreede MJ, Huisman MV; Vesta Study Investigators. Efficacy and Safety of Outpatient Treatment Based on the Hestia Clinical Decision Rule with or without N-Terminal Pro-Brain Natriuretic Peptide Testing in Patients with Acute Pulmonary Embolism. A Randomized Clinical Trial. Am J Respir Crit Care Med 2016;194:998-100
3. van der Hulle T, Kooiman J, den Exter PL, Dekkers OM, Klok FA, Huisman MV. Effectiveness and safety of novel oral anticoagulants as compared with vitamin K antagonists in the treatment of acute symptomatic venous thromboembolism: a systematic review and meta-analysis. J Thromb Haemost 2014;12:320-328