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Home Formulary 2.0 Cardiovascular System 2.8 Anticoagulants and protamine 2.8.2 Oral anticoagulants 2.8.2.2 Treatment of pulmonary embolism and deep vein thrombosis and prevention of recurrent

2.8.2.2 Treatment of pulmonary embolism and deep vein thrombosis and prevention of recurrent

For advice on warfarin monitoring during the Covid-19 pandemic, refer to MHRA guidance.

ChoiceDrugDosage

1st choices

See prescribing note below re NICE preferred anticoagulant choices

Apixaban tablets 2.5mg, 5mgDose:
Treatment of DVT or PE, initial treatment 10mg twice daily for 7 days, then 5mg twice daily for continued treatment

Prophylaxis of recurrent DVT or PE, 2.5mg twice daily (following completion of 6 months anticoagulant treatment)
Or
Dabigatran capsules 110mg, 150mgDose:
Treatment of DVT and PE, and prophylaxis of recurrent DVT and PE, 150mg (ELDERLY over 80 years or receiving concomitant treatment with verapamil, 110mg) twice daily, following at least 5 days treatment with a parenteral anticoagulant. (Lower dose of 110mg may be considered for patients aged 75-79 years, or with moderate renal impairment, or at increased risk of bleeding)
Or
Edoxaban▼ 30mg, 60mg tabletsDose:
Treatment of DVT, PE and prevention of recurrent DVT and PE, 60mg once daily following initial use of parenteral anticoagulant for at least 5 days. Duration of therapy should be individualised (see SPC)

Lower dose of 30mg once daily in patients with one or more of the following:
·        Moderate or severe renal impairment (creatinine clearance (CrCL) 15 - 50 mL/min)
·        Low body weight ≤ 60 kg
·        Concomitant use of ciclosporin, dronedarone, erythromycin, or ketoconazole
Or
Rivaroxaban▼15mg, 20mg tablets

Dose:
Treatment of DVT or PE
Initially 15mg twice daily for 21 days, then maintenance 20mg once daily, to be taken with food, for duration of treatment, contact product literature

Renal Impairment*:
Moderate (CrCl 30-49mL/min) or severe renal impairment (CrCl 15-29mL/min), patients should be treated with 15mg twice daily for the first 21 days. Thereafter the recommended dose is 20mg once daily (a reduction of the continuation dose from 20mg once daily to 15mg once daily should be considered if the patient’s assessed risk for bleeding outweighs the risk for recurrent DVT and PE)

*Use with caution in patients with severe renal impairment (CrCl 15-29mL/min)
Use is not recommended in patients with CrCl<15mL/min

Prophylaxis of recurrent DVT or PE

10mg once daily, following completion of at least 6 months of anticoagulant treatment, to be taken with food, consider 20mg once daily in those at high risk of recurrence (such as complicated comorbidities, or previous recurrence with rivaroxaban 10mg once daily)

Renal impairment: When the recommended dose is 20mg once daily (ie in those at high risk of recurrence), manufacturer advises consider reducing to 15mg once daily if CrCl 15-49mL/min and the risk of bleeding outweighs the risk of recurrent DVT or PE.

Or
Warfarin tablets 1mg, 3mgDose:
See BNF (as per INR)

Prescribing Notes

  • Refer to NICE guidance on anticoagulation treatment for venous thromboembolism (NICE make recommendations on preferred anticoagulant choices; these vary depending on co-morbidities/ clinical features. Apixaban or rivaroxaban are recommended first line in patients with no relevant co-morbidities or significant clinical features.)
  • Please note dosing schedule. A number of incidents have been reported where the initial twice daily dose for rivaroxaban▼ was continued beyond the 21 days following discharge from hospital, presenting a significant risk to patients. This type of incident is also possible with apixaban. Refer to table above.

Cautions

See here.

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