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. 2024 Apr 26;8(4):102424. doi: 10.1016/j.rpth.2024.102424

Direct oral anticoagulants for treatment of venous thrombosis: illustrated review of appropriate use

Candrika D Khairani 1, Antoine Bejjani 1, Ali Assi 1, Nicole Porio 1, Azita H Talasaz 2,3, Gregory Piazza 1,4, Mary Cushman 5, Behnood Bikdeli 1,4,6,7,∗
PMCID: PMC11135034  PMID: 38812988

Abstract

Direct oral anticoagulants (DOACs) have become the preferred option for treatment of venous thromboembolism due to their favorable profile compared with other agents such as vitamin K antagonists or low-molecular-weight heparin. However, findings from randomized controlled trials suggest efficacy and/or safety concerns with DOAC use in some clinical contexts. This illustrated review will summarize indications where DOACs have proven efficacy and safety, situations where they fall short, and situations where uncertainty remains compared with other treatments for venous thromboembolism.

Keywords: anticoagulants, direct oral anticoagulants, low-molecular-weight heparin, venous thromboembolism, Vitamin K Antagonists

Essentials

  • •

    Randomized trials suggest that direct oral anticoagulants (DOACs) may not be as safe or effective for mangement of venous thromboembolism (VTE) in certain situations.

  • •

    We review scenarios where DOACs are safe and effective, where they have reduced safety or efficacy, and when their safety and/or efficacy are uncertain.

  • •

    DOACs are not advised for VTE in antiphospholipid syndrome or luminal cancers.

  • •

    The safety and efficacy of DOACs for VTE remain uncertain in some conditions.

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Acknowledgments

This illustrated review follows strict ethical guidelines, ensuring that all data, images, and figures used are properly attributed and cited to maintain accuracy and integrity. All authors contributed to the scientific content and review editing, with CDK leading the conceptualization and design of illustrations, and BB providing supervision, direction, and final approval. Capsules were created with BioRender.com.

Funding

The authors received no funding for this study.

Relationship disclosure

Outside the submitted work, Dr Bikdeli is supported by a Career Development Award from the American Heart Association and VIVA Physicians (#938814). B.B. was supported by the Scott Schoen and Nancy Adams IGNITE Award and is supported by the Mary Ann Tynan Research Scientist award from the Mary Horrigan Connors Center for Women’s Health and Gender Biology at Brigham and Women’s Hospital and the Heart and Vascular Center Junior Faculty Award from Brigham and Women’s Hospital. Dr Bikdeli reports that he was a consulting expert, on behalf of the plaintiff, for litigation related to 2 specific brand models of Inferior Vena Cava filters. Dr Bikdeli has neither been involved in the litigation in 2022-2024 nor has he received any compensation in 2022-2024. Dr Bikdeli reports that he is a member of the Medical Advisory Board for the North American Thrombosis Forum and serves in the Data Safety and Monitory Board of the NAIL-IT trial funded by the National Heart, Lung, and Blood Institute, and Translational Sciences. Dr Bikdeli is a collaborating consultant with the International Consulting Associates and the US Food and Drug Administration in a study to generate knowledge about utilization, predictors, retrieval, and safety of IVC filters. Dr Bikdeli receives compensation as an associate editor for the New England Journal of Medicine Journal Watch Cardiology, as an associate editor for Thrombosis Research, and as an executive associate editor for Journal of the American College of Cardiology and is a section editor for Thrombosis and Haemostasis (no compensation). Dr Piazza has received research support from Bristol-Myers Squibb/Pfizer Alliance, Bayer, Janssen, Alexion, Amgen, Esperion, Boston Scientific Corporation, and the National Heart, Lung, and Blood Institute (1R01HL164717-01) and consulting/advisory fees from BMS, Boston Scientific Corporation, Janssen, PERC, NAMSA, Regeneron, Penumbra, and Amgen.

Footnotes

Handling Editor: Dr Michael Makris

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