What is the dose of Direct Oral Anticoagulant (DOAC) for Pulmonary Embolism (PE)?

From the Guidelines

For patients with pulmonary embolism (PE), the recommended dose of direct oral anticoagulants (DOACs) after 6 months of therapeutic anticoagulation is a reduced dose, such as apixaban 2.5 mg twice daily or rivaroxaban 10 mg once daily 1. When considering the treatment of PE with DOACs, it's essential to note that the initial doses are typically higher, but after 6 months, a reduced dose can be considered to minimize bleeding risks while still providing adequate anticoagulation. Some key points to consider when prescribing DOACs for PE include:

• Apixaban is initially given at 10 mg twice daily for 7 days, then 5 mg twice daily thereafter
• Rivaroxaban is administered at 15 mg twice daily for 21 days, followed by 20 mg once daily
• Edoxaban requires initial parenteral anticoagulation for 5-10 days, then 60 mg once daily (or 30 mg once daily for patients weighing ≤60 kg)
• Dabigatran also requires 5-10 days of parenteral anticoagulation before starting 150 mg twice daily It's also important to consider dose adjustments for patients with renal impairment, low body weight, or those taking certain interacting medications, as outlined in the 2024 ESC guidelines for the management of atrial fibrillation 1. The decision to extend anticoagulation should be based on the patient's risk factors for recurrence and bleeding complications, and regular assessments of drug tolerance, hepatic and renal function, and bleeding risk should be performed 1.

From the FDA Drug Label

Treatment of DVT and/or PE: 15 mg orally twice daily with food for the first 21 days followed by 20 mg orally once daily with food for the remaining treatment ( 2.1) The recommended dose of rivaroxaban for the treatment of pulmonary embolism (PE) is:

• 15 mg orally twice daily with food for the first 21 days
• 20 mg orally once daily with food for the remaining treatment 2

From the Research

DOAC Dosing for Pulmonary Embolism

• The dosing of Direct Oral Anticoagulants (DOACs) for Pulmonary Embolism (PE) is crucial for effective treatment 3, 4, 5.
• For the initiation phase, the standard doses of DOACs should be used to ensure efficacy 5.
• For the maintenance phase, reduced doses of DOACs can be used, except for edoxaban, which can be used at a reduced dose in venous thromboembolism (VTE) 5.
• Rivaroxaban can be reduced to 10mg once daily after 3 months of administration without a decline in efficacy 4.
• The choice of DOAC and dosing should be individualized based on patient factors, such as risk of recurrence and bleeding risk 3, 6.

Specific DOACs and Dosing

• Apixaban, edoxaban, rivaroxaban, and dabigatran are non-inferior to heparin and warfarin for treating PE and have a lower rate of bleeding 6.
• Rivaroxaban has been shown to be effective and safe for the treatment of acute pulmonary embolism, with no significant difference in thrombus absorption compared to standard therapy 4.
• Edoxaban can be used at a reduced dose in VTE, but the reduced doses used in atrial fibrillation are not applicable in VTE except for edoxaban 5.

Clinical Considerations

• The decision on the duration of anticoagulation should consider both the individual risk of PE recurrence and the individual risk of bleeding 3.
• Patients with a strong transient risk factor have a low risk of recurrence, and anticoagulation can be discontinued after 3 months 3.
• Patients with strong persistent risk factors, such as active cancer, have a high risk of recurrence and should receive anticoagulant treatment of indefinite duration 3.