Rapid Clinical Updates: Updates on Anticoagulation for Hospitalists-Q&A

Q&A - Additional Answers

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This document provides a rapid clinical update on anticoagulation for hospitalists, primarily addressing common questions following a recent presentation in December 2023. Key topics focus on anticoagulation management in conditions such as peripheral artery disease (PAD), chronic coronary artery disease (CAD), deep vein thrombosis (DVT), pulmonary embolism (PE), and in patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD).<br /><br />Regarding aspirin use for PAD or peripheral stents in patients on direct oral anticoagulants (DOACs), aspirin can generally be stopped after the typical dual antiplatelet therapy duration. Chronic CAD data guides PAD treatment only by extrapolation. Hypercoagulability testing is rarely needed inpatient for acute DVT/PE, reserved mostly for special circumstances, and is commonly deferred unless recurrent events occur.<br /><br />For DOAC dosing in advanced CKD and ESRD, apixaban is not well studied in patients with creatinine clearance (CrCl) below 25 but may be used cautiously based on observational data, with dosing adjustments per FDA criteria involving the ABCs (age, body weight, creatinine). Apixaban dosing in ESRD typically follows the FDA approach using two or three of these criteria rather than automatic dose reduction. Bridging with heparin when stopping DOACs for inpatient procedures is rarely necessary; timing of holding and restarting depends on bleeding risk.<br /><br />The consensus encourages individualized shared decision-making when weighing stroke versus bleeding risk in ESRD patients with atrial fibrillation. Aspirin discontinuation in stable CAD patients on DOACs may be appropriate. For subsegmental PE and isolated calf DVT, treatment decisions vary, with recent studies supporting treatment of subsegmental PE and ultrasound monitoring or short-duration anticoagulation for calf DVT.<br /><br />Lastly, left atrial appendage closure is endorsed as a reasonable option in ESRD patients with atrial fibrillation who have limited life expectancy but elevated risks. Cost remains a less common but present barrier in anticoagulation therapy access. Overall, the updates reflect nuanced, evidence-informed clinical judgment tailored to complex patient factors.

Keywords

anticoagulation

hospitalists

peripheral artery disease

chronic coronary artery disease

deep vein thrombosis

pulmonary embolism

chronic kidney disease

end-stage renal disease

direct oral anticoagulants

left atrial appendage closure