Indefinite anticoagulation with direct oral anticoagulants (DOACs) is increasingly being recommended after symptomatic venous thromboembolism (VTE) in many clinical scenarios. This is because of the ease of use and lower bleeding risk of DOACs compared with warfarin and cumulative evidence of recurrence risk if anticoagulants are stopped, particularly after unprovoked VTE. The decision for extended use should be tailored to each patient, based on the risk of recurrence and bleeding, and patient preference.
- Patients with symptomatic venous thromboembolism (VTE) associated with a major provoking factor can usually stop anticoagulation after three to six months.
- Patients with a persisting provoking factor, including malignancy or antiphospholipid syndrome, and those with recurrent unprovoked VTE should receive anticoagulation indefinitely.
- The decision to extend anticoagulation beyond three to six months among those with first unprovoked or minimally provoked VTE is nuanced, and based on the individual’s recurrence and bleeding risk and patient preference.
- Radiological findings at the end of the treatment phase of anticoagulation (three to six months) should not dictate duration of anticoagulation but are useful to establish a new baseline.
- Monitoring patients on extended anticoagulation should include six- to 12-monthly assessment of renal and liver function, bleeding risk and new medications.