What medications are used to treat pulmonary embolism?

From the Guidelines

Medications used to treat pulmonary embolism primarily include anticoagulants, such as unfractionated heparin (UFH), low molecular weight heparins (LMWHs), and direct oral anticoagulants (DOACs), which prevent further clot formation while the body naturally dissolves the existing clot.

Initial Treatment

Initial treatment typically involves anticoagulation with UFH, including a weight-adjusted bolus injection, which should be initiated without delay in patients with high-risk pulmonary embolism (PE) 1.

• Low molecular weight heparins (LMWHs) such as enoxaparin (1 mg/kg twice daily or 1.5 mg/kg once daily) or fondaparinux (5-10 mg daily based on weight) may also be used.
• For long-term treatment, direct oral anticoagulants (DOACs) like apixaban, rivaroxaban, edoxaban, or dabigatran are preferred due to their effectiveness and convenience 1.

Thrombolytic Therapy

In massive, life-threatening PEs, thrombolytic medications like alteplase may be administered to rapidly dissolve clots 1.

• Systemic thrombolytic therapy is recommended for high-risk PE 1.
• Surgical pulmonary embolectomy is recommended for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed 1.

Additional Considerations

Patients should be monitored for bleeding complications, the most significant risk of anticoagulation therapy, and should inform all healthcare providers about their anticoagulant use.

• Treatment duration typically ranges from 3-6 months for provoked PEs to indefinite therapy for unprovoked or recurrent events.
• Norepinephrine and/or dobutamine may be considered in patients with high-risk PE 1.
• ECMO may be considered, in combination with surgical embolectomy or catheter-directed treatment, in patients with PE and refractory circulatory collapse or cardiac arrest 1.

From the FDA Drug Label

The primary efficacy endpoint was confirmed, symptomatic, recurrent VTE reported up to Day 97. In a randomized, open-label, clinical trial in patients with a confirmed diagnosis of acute symptomatic PE, with or without DVT, fondaparinux sodium 5 mg (body weight <50 kg), 7. 5 mg (body weight 50 to 100 kg), or 10 mg (body weight >100 kg) SC once daily (fondaparinux sodium treatment regimen) was compared to heparin intravenous bolus (5,000 USP units) followed by a continuous intravenous infusion adjusted to maintain 1.5 to 2. 5 times aPTT control value.

The medications used to treat pulmonary embolism are:

• Fondaparinux sodium: 5 mg, 7.5 mg, or 10 mg SC once daily
• Heparin: intravenous bolus (5,000 USP units) followed by a continuous intravenous infusion adjusted to maintain 1.5 to 2.5 times aPTT control value 2

From the Research

Medications for Pulmonary Embolism

The following medications are used to treat pulmonary embolism:

• Unfractionated heparin 3, 4, 5, 6, 7
• Low molecular weight heparins (LMWHs) 3, 4, 5, 6, 7
• Oral anticoagulants (such as warfarin) 3, 4, 5
• Fondaparinux 3, 6, 7
• Direct oral anticoagulant drugs (DOACs) 6
• Thrombolytic drugs (such as hirudin and its analogues) 4, 5, 7
• Ximelagatran (an oral direct thrombin inhibitor) 3
• Idraparinux (a selective factor X(a) inhibitor) 3
• Rivaroxaban 7
• Enoxaparin 7
• Dalteparin 7
• Nadroparin 7

Treatment Regimens

The treatment regimens for pulmonary embolism include:

• Initial treatment with unfractionated heparin or LMWHs 3, 4, 5, 6, 7
• Long-term anticoagulation with oral anticoagulants (such as warfarin) 3, 4, 5
• Use of fondaparinux or DOACs as alternatives to LMWHs and oral anticoagulants 3, 6, 7
• Thrombolytic therapy for massive pulmonary embolism 4, 5, 7

Special Considerations

Special considerations for the treatment of pulmonary embolism include:

• Patients with renal failure may require unfractionated heparin instead of LMWHs 7
• Patients with massive pulmonary embolism may require thrombolytic therapy 4, 5, 7
• Outpatient management may be acceptable for some patients with deep venous thrombosis or pulmonary embolism 7