Treatment of venous thromboembolism in a 22-year-old woman taking an oral contraceptive pill

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Date: Nov. 27, 2017
From: CMAJ: Canadian Medical Association Journal(Vol. 189, Issue 47)
Publisher: CMA Joule Inc.
Document Type: Clinical report
Length: 1,502 words
Lexile Measure: 1750L

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A previously healthy 22-year-old woman presented to the emergency department with shortness of breath. She had been taking a combined oral contraceptive pill since the age of 17 years. Computed tomographic pulmonary angiography confirmed the diagnosis of pulmonary embolism and she was started on rivaroxaban. She is seeing her family physician for follow-up.

Has the patient been prescribed an appropriate anticoagulant?

Direct oral anticoagulants are the preferred initial treatment for acute venous thromboembolism in ambulatory patients without cancer. Several randomized controlled trials (RCTs) on acute venous thromboembolism have found direct oral anticoagulants to be noninferior to standard therapy--consisting of enoxaparin (lowmolecular-weight heparin) followed by warfarin (vitamin K antagonist) --in reducing recurrent venous thromboembolism. (1,2) Safety outcomes of dabigatran and rivaroxaban showed no significant difference in bleeding risk compared with standard therapy, while apixaban and edoxaban reduced the absolute risk of major or clinically relevant nonmajor bleeding by 5.4% and 1.8%, respectively. (1-4)

Direct oral anticoagulants are more convenient than vitamin K antagonists, because they do not require laboratory monitoring and there are fewer drug interactions and no known food interactions. However, they are more expensive than vitamin K antagonists and dependent on renal clearance. The American College of Chest Physicians guideline recommends direct oral anticoagulants over vitamin K antagonists as first-line therapy for venous thromboembolism in patients who do not have cancer. (5)

Should the patient stop taking the oral contraceptive pill?

It appears safe to continue the combined oral contraceptive pill in patients with acute venous thromboembolism who are receiving anticoagulation. A subgroup analysis of 1888 women younger than 60 years of age who had been enrolled in an RCT of rivaroxaban versus standard therapy for acute venous thromboembolism found hormonal therapy was not associated with increased risk of recurrent venous thromboembolism during therapeutic anticoagulation. (6)

In addition, continuing the oral contraceptive pill is a simple and effective method to ensure that women who receive anticoagulation also receive contraception, which decreases the risk of fetal exposure to oral anticoagulation. Both vitamin K antagonists and direct oral anticoagulants are contraindicated in pregnancy. (5)

Immediately stopping the oral contraceptive pill in a woman who requires anticoagulation with direct oral anticoagulants may substantially worsen menorrhagia, potentially leading to decreased quality of life and iron deficiency anemia. Direct...

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Gale Document Number: GALE|A517261914