The Curbsiders Internal Medicine Podcast

Episode: UNLOCKED PATREON #60 Anticoagulation DVT/PE
Date: December 29, 2025
Featured Guest: Dr. Tara Lech, PharmD, Anticoagulation Forum
Hosts: Dr. Matthew Frank Watto (“Matt”), Dr. Paul Nelson Williams (“Paul”)

Episode Overview

This episode delivers an evidence-based, practical discussion on the management of anticoagulation for venous thromboembolism (VTE)—specifically deep vein thrombosis (DVT) and pulmonary embolism (PE). The hosts and expert PharmD Tara Lech review modern best practices for agent selection, dosing duration, special circumstances, and address common clinical dilemmas. Released in the wake of headlines about the U.S. withdrawal of adexanet alfa (a factor Xa inhibitor reversal agent), the episode also incorporates timely safety updates. The style is conversational, high-yield, and peppered with humor.

Key Discussion Points & Clinical Insights

1. Update on Adexanet Alfa Withdrawal

• Context: Adexanet alfa is no longer available in the U.S. due to increased risk of thrombosis found in the ANNEXA-1 trial (00:00–01:34). AstraZeneca has stopped selling it domestically.
• Pearl: Be aware that this reversal agent for factor Xa inhibitors should not be used; alternatives may vary by country.

2. Choosing a DOAC for Initial VTE Therapy

• Practice Trend: Preference for Apixaban (“Eliquis”) over Rivaroxaban (“Xarelto”) if insurance allows (04:20).
• Rationale:
  • Renal Insufficiency: Apixaban favored due to easier dosing (see [04:20–05:11]).
  • Bleeding Risk: COBRA trial shows lower bleeding with Apixaban (05:11).
  • Uncommon Options: Dabigatran is rarely used—requires parenteral bridging and increased GI side effects (05:54–06:29).
• Quotable: “In general, apixaban, if you can get away with it, just seems to be kind of the easier choice.” – Paul (04:54)

3. Starter Packs & Initial Dosing Rationale

• Why High Initial Doses?
  • Risk of VTE recurrence is highest early after the event, so initial dosing is “front-loaded.”
  • Use of starter packs also reflects clinical trial methodology (06:45–07:56).
  • Practical tip: Count inpatient doses flexibly when deciding what to prescribe at discharge.
• Quotable: “It's just easier or less confusing for them.” – Matt on matching starter pack days with inpatient dosing (07:17)

4. Duration of Therapy

• Provoked vs. Unprovoked:
  • Provoked VTE (e.g., post-surgery): Stop after 3 months.
  • Unprovoked VTE: Consider lifelong anticoagulation (07:56–08:28).
• Guideline Gap:
  • Many patients expect 3–6 months from guidelines; reality is more dichotomous—3 months or lifelong.
• Quotable: “For me, it’s either like three months or lifelong and there's not a whole lot in between there.” – Paul (08:20)

5. Hypercoagulable Workups—Just Say No?

• Avoid indiscriminate hypercoagulable testing; only consider in selected cases (08:28–09:49).
  • Best Indication: Young patients with unusual clot sites (e.g., cerebral, splanchnic), history of lupus, family history.
  • Antiphospholipid Syndrome: Test matters before starting anticoagulation and must persist at 12 weeks for diagnosis (09:49).
• Quotable: “I try to talk people out of hypercoagulable workups… they’re already dead set…” – Matt (08:28)

6. Peri-Travel Anticoagulation

• Case: Patient with high recurrence risk declines chronic anticoagulation but is planning prolonged travel (09:49–11:36).
• Strategy: Temporary DOAC during travel (e.g., apixaban 2.5mg BID or rivaroxaban 10mg daily).
• Travel Caveats: Assess all travel plans (flights, car rides), not just flights.
• Quotable: “You can actually anticoagulate for the duration of the flight.” – Paul (11:06)

7. Distal DVT—To Treat or Not to Treat?

• Clinical Dilemma: Guidelines allow monitoring with serial ultrasounds, but most treat symptomatic cases (12:27–13:25).
• Implementation Challenges: Patient compliance with repeat ultrasounds is low; treating is often simpler.

8. DOACs in Obesity and Extremes of Weight

• New Evidence: DOACs okay for BMI >40 as long as actual weight <150kg; main concern is malabsorption in post-bariatric surgery (13:25–15:09).

9. Suspected Treatment Failure

• First Steps:
  • Assess adherence, missed doses, new medications, or other factors before labeling as true failure (15:10–15:48).
  • Consult hematology for further management.

10. Anticoagulation Management for Surgery

• In Practice:
  • Primary care typically manages pre-op anticoagulant hold for elective surgery (17:03–17:28).
  • Surgeons may weigh in for ortho post-op prophylaxis, not usually for chronic therapy (17:28).
  • Complex cases (e.g. antiphospholipid, sickle cell): involve hematology.

11. Audience Q&A

a. Uncertain Osteoporosis History (19:02–21:36):

• If history of bisphosphonates (alendronate, zoledronic acid) unclear, get baseline DEXA.
• Treat per guidelines if new fracture or poor DEXA/FRAX, regardless of hazy prior therapy.
• Drug holiday benefit: Atypical femur fracture risk declines rapidly off-therapy (21:09).
• Quotable: “If this has been long enough... it’s probably been more than 15 months and that risk is probably diminished.” – Matt (21:27)

Notable Quotes & Memorable Moments

• “Well, Matt, by and large, it seems like we're picking apixaban.” – Paul (04:21)
• “I hate [distal DVTs] so much, man.” – Paul (12:27)
• “I think the easier thing is the patient’s willingness to just treat them.” – Matt (13:17)
• “If someone had the treatment or medication and particularly a DOAC, I would probably send the hematology...” – Paul (15:32)

Timestamps for Important Segments

• 00:00–01:34: Adexanet alfa withdrawal context
• 04:20–05:11: DOAC selection rationale
• 06:29–07:56: Starter pack/high-dose initiation explained
• 07:56–09:49: Duration of anticoagulation (provoked/unprovoked)
• 09:49–11:36: High recurrence risk + travel: temporary DOACs
• 12:27–13:25: Approach to distal (calf) DVT
• 13:25–15:09: DOACs in obesity/extremes of weight; post-bariatric caveat
• 15:10–15:48: Approach to apparent treatment failure
• 17:03–17:28: Perioperative anticoagulation management
• 19:02–21:36: Approach to osteoporosis therapy with unclear prior history

Tone, Humor & Character

The hosts’ banter is a highlight:

• Seafood disco jokes and cheese puns set a playful, lighthearted tone (01:34–02:48).
• Self-deprecating humor: “I hate uncertainty.” – Paul (12:27)
• Book and videogame recommendations lighten the atmosphere—Joe Pickett novels (Matt, 21:52) and Death Stranding 2 (Paul, 22:56), with quirky, passionate digressions.

Conclusion

This is a high-yield, clinically practical episode for anyone managing VTE and anticoagulation, with actionable pearls, guideline perspectives, and nuanced answers to common scenarios. Dr. Tara Lech’s guidance and the hosts’ lively dynamic ensure listeners come away with up-to-date knowledge they can use at the bedside.