Drug Selection for Long-Term Anticoagulant Therapy in Patients with Venous Thromboembolism

Following completion of the primary phase of anticoagulant therapy (ACT) in patients with venous thromboembolic complications (VTEs), discontinuation of anticoagulant agents significantly increases the risk of recurrent venous thrombosis and pulmonary embolism. This consideration provides a compelling rationale for continuing therapy. However, the long-term use of anticoagulants may lead to hemorrhagic complications, which can be life-threatening. Clinicians are thus faced with the critical challenge of balancing the benefits against the risks associated with long-term therapy, while also developing strategies to shift this balance in favor of benefits. One potential method to improve therapeutic outcomes is selecting the appropriate anticoagulant. While different anticoagulants have similar effectiveness, they also exhibit variable safety profiles and associated risks of hemorrhagic events. This literature review evaluates available data on ACT to identify an anticoagulant that effectively mitigates the risk of VTE progression and recurrence without increasing the risk of bleeding complications. Coagulation factor Xa inhibitors are preferred alternatives to vitamin K antagonists due to their lower need for routine laboratory monitoring, enhanced patient adherence, and lower risk of hemorrhagic complications, allowing dose reductions during long-term ACT while maintaining therapeutic efficacy. Comparisons between apixaban and rivaroxaban, particularly regarding VTE treatment, had been largely confined to observational studies until recently. However, data from a randomized controlled trial assessing treatment outcomes with these two agents during the first 3 months post-venous thrombosis have indicated a superior safety profile for apixaban compared with rivaroxaban.