Equivalent Treatment Options
In their systematic review, Heil et al. point to an issue that is also important in primary care, which we too seldom consider when presented with complaints about the upper extremity (1).
However, the subjective assessment of the authors regarding maintenance therapy, which compares the use of vitamin K antagonists (VKA) (usually phenprocoumon in Germany) with NOACs/DOACs, cannot remain unchallenged. Although major bleeding events for NOACs/DOACs occur less frequently, the risk of gastrointestinal bleeding is significantly higher (at least in the studies comparing VKAs with NOACs/DOACs in treating nonvalvular atrial fibrillation) (2). The authors furthermore omit to mention the fact that the number needed to treat to prevent a fetal bleeding with NOACs/DOACs as compared to VKA is 1:111 (3). Also, in contrast to the German guideline, the authors do not point out that there are no NOAC/DOAC studies on upper-extremity deep vein thrombosis. Additionally, during 2016, the number of reports of serious side effects for phenprocoumon submitted to the Drug Commission of the German Medical Association (28 reports) was clearly exceeded by the more than 175 reports for NOACs/DOACs (excluding those for edoxaban) (although this may be due to willingness to report new substances rather than established ones) (4).
It is therefore difficult to understand why VKAs are not listed in the Table. Thus, VKA therapy—which in my opinion is as valid for this indication as other drugs—should remain an option.
Finally, the fact that low-molecular-weight heparins are not approved for maintenance therapy of thromboembolism, and that doing so would formally be an off-label use, is not mentioned.
Dr. med. Thomas Maibaum
Conflict of interest statement
The author declares that no conflict of interest exists.
|1.||Heil J, Miesbach W, Vogl T, Bechstein WO, Reinisch A: Deep vein thrombosis of the upper extremity—a systematic review. Dtsch Arztebl Int 2017; 114: 244–9 VOLLTEXT|
|2.||Leitfaden der Arzneimittelkommission der deutschen Ärzteschaft: Orale Antikoagulation bei nicht valvulärem Vorhofflimmern. 2nd revised edition 2016: 6.|
|3.||van der Hulle T, Kooiman J, den Exter PL, Dekkers OM, Klok FA, Huisman MV: Effectiveness and safety of novel oral anticoagulants as compared with vitamin K antagonists in the treatment of acute symptomatic venous thromboembolism: a systematic review and meta-analysis. J Thromb Haemost 2014; 12: 320–8 CrossRef MEDLINE|
|4.||Stammschulte T: Vortrag bei Fortbildungsveranstaltung der AkdÄ in Hamburg am 22.4.2017, Folie 19.|