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

ChoiceDrugDosage
1st choicesWarfarin tablets 1mg, 3mgDose:
See BNF (as per INR)
Or
Apixaban▼ tablets 2.5mg, 5mg Dose: 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 75-80 years, or with moderate renal impairment, or at increased risk of bleeding)
Or
Edoxaban▼ Dose:
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. Edoxaban and initial parenteral anticoagulant should not be administered simultaneously. 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 tabletsDose:
Treatment of DVT or PE, initial treatment 15mg twice daily with food for 21 days, then for continued treatment and prophylaxis of recurrent DVT and PE, 20mg once daily with food
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

Prescribing Notes

  • Apixaban, rivaroxaban and dabigatran have been approved by NICE as options for the treatment of pulmonary embolism (PE) and deep vein thrombosis (DVT) and prevention of recurrent DVT and PE in adults. See link.
  • 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▼. See HSC Learning letter re icidents involving newer oral anticoagulant (NOAC) dosing.
  • MHRA have received a small number of reports suggesting lack of efficacy (thromboembolic events) in patients taking 15mg or 20mg rivaroxaban on an empty stomach; remind patients to take rivaroxaban 15mg or 20mg tablets with food.

Cautions

See here.