What is the treatment for Pulmonary Embolism (PE)?

From the Guidelines

The treatment of pulmonary embolism (PE) typically involves anticoagulation therapy as the cornerstone of management, with direct oral anticoagulants (DOACs) like rivaroxaban, apixaban, or edoxaban preferred for most patients due to their efficacy, safety profile, and convenience, as recommended by the 2019 ESC guidelines 1. For most patients with acute PE, anticoagulation should be initiated immediately, with the choice of anticoagulant depending on the patient's clinical characteristics and risk factors.

• Low molecular weight heparin (LMWH) such as enoxaparin 1 mg/kg twice daily or fondaparinux 5-10 mg daily (weight-based) may be used as initial anticoagulation, followed by oral anticoagulants.
• DOACs like rivaroxaban (15 mg twice daily for 21 days, then 20 mg daily), apixaban (10 mg twice daily for 7 days, then 5 mg twice daily), or edoxaban (60 mg daily after initial parenteral anticoagulation) are preferred for most patients due to their efficacy, safety profile, and convenience, as supported by the 2019 ESC guidelines 1.
• Warfarin (target INR 2-3) remains an alternative, particularly for patients with severe renal impairment or mechanical heart valves. Anticoagulation should typically continue for at least 3 months, with extended therapy considered for unprovoked PE or ongoing risk factors, as recommended by the 2019 ESC guidelines 1. For hemodynamically unstable patients with massive PE, thrombolytic therapy with alteplase (100 mg IV over 2 hours) should be considered, as supported by the 2020 guidelines 1. Inferior vena cava filters are reserved for patients with contraindications to anticoagulation or recurrent PE despite adequate anticoagulation, as recommended by the 2019 ESC guidelines 1. Anticoagulation prevents further clot formation and allows the body's natural fibrinolytic system to dissolve existing clots, reducing the risk of PE extension and recurrence while the body works to restore normal pulmonary circulation, as supported by the landmark study 1.

From the FDA Drug Label

1 INDICATIONS & USAGE

1. 4 Treatment of Pulmonary Embolism Apixaban tablets are indicated for the treatment of PE.

1 INDICATIONS AND USAGE

1. 3 Treatment of Pulmonary Embolism XARELTO is indicated for the treatment of pulmonary embolism (PE).

Treatment of Pulmonary Embolism (PE) is indicated for both apixaban 2 and rivaroxaban 3.

• Apixaban is indicated for the treatment of PE.
• Rivaroxaban is also indicated for the treatment of PE.

From the Research

Treatment Options for Pulmonary Embolism (PE)

• The initial treatment of haemodynamically stable patients with PE has dramatically changed since the introduction of low molecular weight heparins (LMWHs) 4.
• Direct oral anticoagulant drugs (DOACs) are becoming the agents of first choice for the initial treatment of PE due to their practicability, due to several large clinical trials demonstrating that DOACs are not inferior to standard therapy for the initial treatment of PE 4.
• LMWHs will continue to play an important role in initial PE treatment, and in some cases, there still is a role for unfractionated heparin (UFH) 4.
• Treating PE requires appropriate risk stratification as a first step, with different treatment strategies for high-risk, intermediate-risk, and low-risk PE patients 5.
• For high-risk PE, presenting as shock or arrest, emergent systemic thrombolysis or embolectomy is reasonable, while for low-risk PE, anticoagulation alone is often chosen 5.

Anticoagulation Therapy

• Rivaroxaban may be used in haemodynamically stable patients since the first day of therapy and has been associated with a significant reduction of the duration of hospital stay compared to standard therapy 6.
• The use of rivaroxaban has been recommended by the European Society of Cardiology guidelines on the diagnosis and management of acute pulmonary embolism (APE) for patients at a low-to-moderate risk of early mortality 6.
• Other anticoagulants that have been used for treatment of PE include warfarin, unfractionated heparin (UFH), and low-molecular-weight heparins, as well as newer oral anticoagulants such as dabigatran and apixaban 7.

Contemporary Management of Acute Pulmonary Embolism

• Diagnostic strategies allowing the safe decrease of imaging testing have been proposed, and new modalities of catheter-based interventions have emerged for hemodynamically unstable PE patients 8.
• For normotensive PE patients, direct oral anticoagulant treatment has become the new norm, and a large proportion of patients are eligible for home treatment 8.
• A Pulmonary Embolism Response Team can help determine which intervention, such as catheter-directed fibrinolysis, ultrasound-assisted thrombolysis, percutaneous mechanical thrombus fragmentation, or percutaneous or surgical embolectomy, is best suited to a particular patient 5.