From the Guidelines
Peripheral Pulmonary Embolism Management
Anticoagulation is the primary treatment for peripheral pulmonary embolism (PPE) management.
- It is recommended to start with low molecular weight heparin (LMWH) such as enoxaparin 1mg/kg subcutaneously twice daily or unfractionated heparin (UFH) 80 units/kg bolus followed by 18 units/kg/hour continuous infusion, adjusted to maintain aPTT between 60-80 seconds 1.
- Alternatively, fondaparinux 5mg subcutaneously once daily (or 10mg for patients over 100kg) can be used.
- For patients with severe kidney disease, UFH or LMWH with dose adjustment based on anti-Xa levels is preferred.
Long-term Anticoagulation
Direct oral anticoagulants (DOACs) such as rivaroxaban 15mg orally twice daily for 21 days, then 20mg once daily, or apixaban 10mg orally twice daily for 7 days, then 5mg orally twice daily, can be considered for long-term anticoagulation 1.
- The duration of anticoagulation should be at least 3-6 months, and extended based on individual risk assessment.
Monitoring and Thrombolytic Therapy
In addition to anticoagulation, patients should be monitored for signs of clinical deterioration, and thrombolytic therapy with alteplase 100mg intravenously over 2 hours can be considered in selected cases with severe peripheral pulmonary embolism and low bleeding risk 1.
- Systemic thrombolytic therapy using a peripheral vein is suggested over catheter-directed thrombolysis (CDT) in patients treated with a thrombolytic agent 1.
Key Considerations
- The management of PPE should be individualized based on the patient's risk factors, comorbidities, and clinical presentation.
- Regular follow-up examinations are essential to monitor for signs of VTE recurrence, cancer, or bleeding complications of anticoagulation, and to assess for persisting or new-onset dyspnea or functional limitation 1.
From the FDA Drug Label
1.4 Treatment of Pulmonary Embolism
Apixaban tablets are indicated for the treatment of PE.
1.5 Reduction in the Risk of Recurrence of DVT and PE
Apixaban tablets are indicated to reduce the risk of recurrent DVT and PE following initial therapy.
The management of peripheral pulmonary embolism (PPE) is not directly addressed in the provided drug labels. However, the labels do discuss the treatment of pulmonary embolism (PE).
- Apixaban is indicated for the treatment of PE 2.
- Fondaparinux is also used in the treatment of PE, with a treatment regimen that includes a once-daily subcutaneous injection, and is compared to heparin in clinical trials 3. Since the labels do not explicitly address peripheral pulmonary embolism (PPE), no conclusion can be drawn about its management.
From the Research
Management of Peripheral Pulmonary Embolism (PPE)
The management of peripheral pulmonary embolism (PPE) primarily involves anticoagulation therapy. The choice of anticoagulant is crucial in preventing further complications and reducing the risk of mortality.
- Anticoagulation Options:
- Direct oral anticoagulants (DOACs) are currently the preferred choice for anticoagulation management in patients with PPE 4, 5, 6, 7.
- Vitamin K antagonists and low-molecular-weight heparin are considered in special populations or selected patients, such as breastfeeding mothers, those with end-stage renal disease, or obese patients 4, 5, 7.
- Initiation and Maintenance of Anticoagulation:
- Long-term Secondary Prevention:
- Reduced dose DOACs are currently a very interesting option in terms of benefit-risk balance for the majority of patients at risk of VTE recurrence 6.
- The selection of anticoagulants should be based on the patient's risk factors and special populations, such as patients with liver failure, renal failure, malignancy, and COVID-19 5.
- Supportive Care and Risk Stratification:
- Appropriate risk stratification and supportive care are crucial to ensure good outcomes in patients with PPE 8.
- The medical management of PPE should focus on the critical care of acute right ventricular failure, anticoagulation of special patient populations, and appropriate follow-up testing after acute PPE 8.