Perspectives: Anticoagulation Management

Sebastian M. Schellong

Sebastian M. Schellong

MD

  • Professor of Medicine
  • Chief of Medical Department 2
  • Municipal Hospital Friedrichstadt
  • Dresden, Germany

Determining the optimal duration of anticoagulation for long-term VTE prevention

German guidelines are in full compliance with the ACCP guidelines. They state that patients shall have three months of anticoagulation, and after that point a risk assessment procedure has to be put in place to determine whether anticoagulation can be stopped entirely, or should be prolonged indefinitely. That is what the guidelines state, but this is not always what physicians follow in Germany.

Physicians are very reluctant to put a patient on long-term anticoagulation for secondary prevention of deep vein thrombosis because of the risk of bleeding, the need for laboratory testing, and all these circumstances which make the patient’s life more complicated.

So physicians follow formulas for their decisions, which deviate from current guidelines, and if you discuss this with different physicians, then everybody has his personal and individual formula. Their decisions are determined, for instance, by the position of clots in the deep veins as assessed by ultrasound. In this case, there is a risk of bleeding, but only a very low number of physicians do use formal risk assessment for bleeding. My impression is that the risk of bleeding is high.

Another argument, which is used more frequently, is the D-dimer test, which is done after 3 or 6 months of anticoagulation, but it is not done in the way it is recommended in the literature. In theory, you should stop anticoagulation for 4 weeks, do the D-dimer test and then, depending on the results, review the need for anticoagulation, or stop it entirely. Many physicians, however, do the D-dimer test under anticoagulation, then they do an evaluation and then they stop anticoagulation.

After this, they evaluate for a second time (using the D-dimer test) and compare the results to the ultrasound information. This process involves a highly individualized approach. My impression is that it is not appropriate at all, but everybody has his or her own formula, and they call it "individualized medicine." I think this does not reflect forward thinking or clinical reasoning.

About the Coagulation Center

The Coagulation Center is an educational resource for healthcare professionals. Guided by a global editorial board of experts, the Coagulation Center offers a range of clinical perspectives on balancing the benefit and risk of anticoagulation in a rapidly changing landscape. Within the Coagulation Center you will find roundtable discussions on anticoagulation management, materials for patient management including patient case studies, tools to help evaluate bleeding risk and stroke risk, and downloadable resources for your practice.