Treatment of upper extremity deep vein thrombosis (DVT) with apixaban or rivaroxaban appears to be as safe and effective as low molecular weight heparin (LMWH) and/or warfarin, according to study results published in the American Journal of Hematology.

Investigators noted large clinical trials that lead to the approval of direct oral anticoagulants to treat venous thromboembolism (VTE) had not included data on upper extremity DVT. Major guidelines on anticoagulation for VTE also lack specific information on upper extremity DVT; however, LMWH has been the recommended treatment for patients with cancer who have catheter-related upper extremity DVT.

This study appears to be the first to compare clinical outcomes in upper extremity DVT for patients treated with apixaban or rivaroxaban compared with the traditional anticoagulation treatment of LMWH and/or warfarin.

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Patients with VTE who had enrolled in the Mayo Clinic VTE Registry from March 1, 2013, to December 31, 2019, were prospectively followed; clinical, demographic, and imaging data were collected.

The primary effectiveness and safety outcomes were symptomatic, recurrent VTE (any site), and major bleeding (according to the International Society of Thrombosis and Hemostasis) at 3 months of follow up. Secondary and tertiary safety outcomes were clinically relevant non-major bleeding and a composting of major bleeding and clinically relevant non-major bleeding, respectively.

In total, 210 patients were included in the study (median age, 60.4 years; 59.3% men); 63 individuals were treated with apixaban, 39 were treated with rivaroxaban, and 108 were treated with LWMH and/or warfarin.

A similar proportion of patients treated with apixaban or rivaroxaban or LWMH/warfarin had catheter-associated upper extremity DVT (44.1% vs 57.4%, respectively; P =.054), concurrent pulmonary embolism (12.7% vs 14.8%, respectively; P =.66), prior VTE (19.4% vs 18.4%, respectively; P =.86), and received chemotherapy at the time of event (39.3% vs 46.3%, respectively; P =.30).

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No difference was observed in recurrent VTE events between the 2 groups (apixaban/rivaroxaban, n=1; LMWH/warfarin, n=1; P =.97).

Similarly, no significant difference was found between the groups in major bleeding events (apixaban/rivaroxaban, n=0; LMWH/warfarin, n=3; P =.09) or clinically relevant non-major bleeding (apixaban/rivaroxaban, n=2; LMWH/warfarin, n=1; P =.53).

“This data, in combination with existing studies, provides reassuring information that the treatment of [upper extremity] DVT with apixaban or rivaroxaban can be considered a reasonable alternative to traditional anticoagulants in appropriate patients,” concluded the authors.


Houghton DE, Casanegra AI, Peterson L, et al. Treatment of upper extremity deep vein thrombosis with apixaban and rivaroxaban [published online April 8, 2020]. Am J Hematol. doi: 10.1002/ajh.25820