anticoagulation for pulmonary embolism (PE)

Last edited 04/2020 and last reviewed 07/2021

Anticoagulation is the main treatment approach in venous thromboembolism treatment.

• patients with proximal DVT/PE should be anticoagulated for at least 3 months


• patients with isolated distal DVT
• at high-risk of recurrence – anticoagulated as for proximal DVT
• at low-risk of recurrence - shorter treatment (4–6 weeks), even at lower anticoagulant doses, or ultrasound surveillance may be considered (1,2)

Current guidelines recommend a two phase anticoagulation treatment:

• initial phase of intensified anticoagulation followed by anticoagulation therapy for 3 months
(3-6 months for patients with active cancer)
• extended phase of anticoagulation
• beyond first 3-6 months
• should consider between the risk for VTE recurrence without long term anticoagulants vs bleeding with anticoagulants (3)

NICE suggest (4):

Anticoagulation treatment for proximal DVT or PE

• measure baseline full blood count, renal and hepatic function, PT and APTT but start anticoagulation before results available. Review and if necessary act on results within 24 hours
• offer anticoagulation for at least 3 months. Take into account contraindications, comorbidities and the person’s preferences
• after 3 months (3 to 6 months for active cancer) assess and discuss the benefits and risks of continuing, stopping or changing the anticoagulant with the person. See long-term anticoagulation for secondary prevention(linked item)

Anticagulatant considerations considered in terms of:

• No renal impairment, active cancer, antiphospholipid syndrome or haemodynamic instability
• offer apixaban or rivaroxaban
• if neither suitable, offer one of:
• LMWH for at least 5 days followed by dabigatran or edoxaban
• LMWH and a VKA for at least 5 days, or until INR at least 2.0 on 2 consecutive readings, then a VKA alone
  
  
• Renal impairment (CrCl estimated using the Cockcroft and Gault formula; see the BNF)
• CrCl 15 to 50 ml/min, offer one of:
• apixaban
• rivaroxaban
• LMWH for at least 5 days then
• edoxaban or
• dabigatran if CrCl >= 30 ml/min
• LMWH or UFH and a VKA for at least 5 days, or until INR at least 2.0 on 2 consecutive readings, then a VKA alone
  
  
• CrCl < 15 ml/min, offer one of:
• LMWH
• UFH
• LMWH or UFH and a VKA for at least 5 days, or until INR at least 2.0 on 2 consecutive readings, then a VKA alone
• Note cautions and requirements for dose adjustments and monitoring in SPCs. Follow local protocols, or specialist or MDT advice


• Active cancer (receiving antimitotic treatment, diagnosed in past 6 months, recurrent, metastatic or inoperable
• Consider a DOAC
• if a DOAC is not suitable, consider one of:
• LMWH
• LMWH and a VKA for at least 5 days or until INR at least 2.0 on 2 consecutive readings, then a VKA alone
• Offer anticoagulation for 3 to 6 months. Take into account tumour site, drug interactions including cancer drugs, and bleeding risk


• Antiphospholipid syndrome (triple positive, established diagnosis)
• Offer LMWH and a VKA for at least 5 days or until INR at least 2.0 on 2 consecutive readings, then a VKA alone

Notes (4):

• PE with haemodynamic instability - Offer continuous UFH infusion and consider thrombolytic therapy
• Body weight
• if body weight <50 kg or >120 kg consider anticoagulant with monitoring of therapeutic levels.
  Note cautions and requirements for dose adjustments and monitoring in SPCs. Follow local protocols, or specialist or MDT advice
• INR monitoring
• Do not routinely offer self-management or self-monitoring of INR
• Prescribing in renal impairment and active cancer
• some LMWHs are off label in renal impairment, and most anticoagulants are off label in active cancer
• Follow GMC guidance on prescribing unlicensed medicines
• Treatment failure
• If anticoagulation treatment fails:
• check adherence
• address other sources of hypercoagulability
• increase the dose or change to an anticoagulant with a different mode of action

Reference:

• (1) Streiff MB et al. Guidance for the treatment of deep vein thrombosis and pulmonary embolism. J Thromb Thrombolysis. 2016;41(1):32-67.
• (2) Mazzolai L et al. Diagnosis and management of acute deep vein thrombosis: a joint consensus document from the European society of cardiology working groups of aorta and peripheral circulation and pulmonary circulation and right ventricular function. Eur Heart J. 2017 Feb 17.
• (3) Wang K-L, Chu P-H, Lee C-H, et al. Management of Venous Thromboembolisms: Part I. The Consensus for Deep Vein Thrombosis . Acta Cardiologica Sinica. 2016;32(1):1-22
• (4)NICE (March 2020). Venous thromboembolic diseases: diagnosis, management and thrombophilia testing.