What about « usual » Anticoagulants ?
Extended treatment of venous thromboembolism with reduced-dose versus full-dose direct oral anticoagulants in patients at high risk of recurrence: a non-inferiority, multicentre, randomised, open-label, blinded endpoint trial (F. Couturaud et al. for the RENOVE investigators, Lancet Vol 405 March 1405: 725–35
In patients with venous thromboembolism at high risk of recurrence for whom extended treatment with direct oral anticoagulants has been indicated, the optimal dose was unknown.
The non-inferiority, investigator-initiated, multicentre, randomised, open-label, blinded endpoint trial RENOVE was done in 47 hospitals in France including 6, 2022, 2768 ambulatory patients aged 18 years or older with acute symptomatic venous thromboembolism (pulmonary embolism or proximal deep vein thrombosis) who had received 6–24 uninterrupted months of full-dose anticoagulation and for whom extended anticoagulation has been indicated were eligible. Eligible participants were categorised as having either a first unprovoked venous thromboembolism, recurrent venous thromboembolism, presence of persistent risk factors, or other clinical situations considered to be a high risk of recurrence. Participants were randomly assigned (1:1) to receive oral treatment with either a reduced dose of apixaban (2·5 mg twice daily) or rivaroxaban (10 mg once daily) or a full dose of apixaban (5 mg twice daily) or rivaroxaban (20 mg once daily) using a centralised randomisation procedure with an interactive web response system.
The primary outcome was symptomatic recurrent venous thromboembolism, including recurrent fatal or non-fatal pulmonary embolism or isolated proximal deep vein thrombosis
Findings concluded that in patients with venous thromboembolism requiring extended anticoagulation, reduction of the direct oral anticoagulant dose did not meet the non-inferiority criteria. However, the low recurrence rates in both groups and substantial reduction of clinically relevant bleeding with the reduced dose could support this regimen as an option. Further research will be needed to identify subgroups for whom the anticoagulation dose should not be reduced.
Extended Reduced-Dose Apixaban for Cancer-Associated Venous Thromboembolism (I. Mahé et al. for the API-CAT Investigators, N Engl J Med 2025;392:1363-73. DOI: 10.1056/NEJMoa2416112)
In patients with active cancer and venous thromboembolism, whether extended treatment with a reduced dose of an oral anticoagulant was effective in preventing recurrent thromboembolic events and decreasing bleeding was unclear.
The randomized, double-blind, noninferiority trial (on 1766 patients with active cancer and proximal deep-vein thrombosis or pulmonary embolism who had completed at least 6 months of anticoagulant therapy) with blinded central outcome adjudication, randomly assigned in a 1:1 ratio to receive oral apixaban at a reduced (2.5 mg) or full (5.0 mg) dose twice daily for 12 months.
The primary outcome was centrally adjudicated fatal or nonfatal recurrent venous thromboembolism, assessed in a noninferiority analysis. The key secondary outcome was clinically relevant bleeding, assessed in a superiority analysis.
Extended anticoagulation with reduced-dose apixaban was noninferior to full-dose apixaban for the prevention of recurrent venous thromboembolism in patients with active cancer. The reduced dose led to a lower incidence of clinically relevant bleeding complications than the full dose.
