From the Guidelines
No, you should not start a NOAC with fondaparinux for pulmonary embolism (PE). Instead, for acute PE treatment, you can either start with a parenteral anticoagulant like fondaparinux or low molecular weight heparin (LMWH) for at least 5-10 days before transitioning to a vitamin K antagonist like warfarin, or you can directly initiate a NOAC such as apixaban, rivaroxaban, dabigatran, or edoxaban 1.
Treatment Options
- If using apixaban, start with 10 mg twice daily for 7 days, then 5 mg twice daily.
- For rivaroxaban, begin with 15 mg twice daily for 21 days, then 20 mg once daily.
- Dabigatran and edoxaban require initial parenteral anticoagulation before starting.
- Fondaparinux is not a NOAC but a synthetic pentasaccharide that works as an indirect factor Xa inhibitor administered subcutaneously, while NOACs are oral medications that directly inhibit either factor Xa or thrombin 1.
Recommendations
- The 2019 ESC guidelines recommend initiating anticoagulation without delay in patients with high or intermediate clinical probability of PE, while diagnostic workup is in progress 1.
- The guidelines also recommend preferring anticoagulation with a NOAC over the ‘traditional’ LMWH-VKA regimen unless the patient has contraindication(s) to this type of drug 1.
- It is essential to weigh the benefits vs. risks of continuing treatment and decide on the extension and dose of anticoagulant therapy, also considering the patient’s preference 1.
Key Points
- NOACs are recommended in preference to a VKA when oral anticoagulation is started in a patient with PE who is eligible for a NOAC 1.
- Fondaparinux and LMWH are preferred over UFH for initial anticoagulation in PE, as they carry a lower risk of inducing major bleeding and heparin-induced thrombocytopenia 1.
- The choice of anticoagulant should be based on the patient's individual risk factors, renal function, and other comorbidities 1.
From the Research
Initial Anticoagulation for Pulmonary Embolism
- The choice of initial anticoagulant for patients with pulmonary embolism (PE) depends on various factors, including the patient's clinical probability of PE, renal function, and the presence of any contraindications to certain anticoagulants 2, 3, 4.
- Low molecular weight heparins (LMWHs) and fondaparinux are preferred over unfractionated heparin (UFH) for initial anticoagulation in normotensive patients with PE, due to their lower risk of bleeding 2, 3.
- Direct oral anticoagulants (DOACs) such as apixaban, edoxaban, rivaroxaban, and dabigatran are non-inferior to standard therapy for treating PE and have a lower rate of bleeding 5, 6, 4.
- The current guidelines recommend the use of DOACs as the first-line treatment for PE, with thrombolysis reserved for patients with systolic blood pressure lower than 90 mm Hg 6.
Use of Fondaparinux and NOACs
- Fondaparinux is an option for initial anticoagulation in patients with PE, particularly those with renal impairment or those who are at high risk of bleeding 2, 3.
- NOACs can be started with fondaparinux in patients with PE, as fondaparinux has a lower risk of bleeding compared to UFH 2, 4.
- The decision to start NOACs with fondaparinux should be based on the individual patient's risk factors and clinical characteristics, as well as the presence of any contraindications to certain anticoagulants 2, 4.
Clinical Considerations
- The choice of initial anticoagulant should be based on a comprehensive assessment of the patient's clinical probability of PE, renal function, and the presence of any contraindications to certain anticoagulants 2, 3, 4.
- Patients with a high or intermediate clinical probability of PE should be initiated on anticoagulation without delay, while awaiting the results of diagnostic tests 2.
- The risk of recurrent PE and bleeding should be carefully considered when deciding on the duration of anticoagulation, with extended anticoagulation recommended for patients with a high risk of recurrence 2, 5.