What is the therapeutic dosing for pulmonary embolism (PE)?

From the Guidelines

Therapeutic anticoagulation for more than 3 months is recommended for all patients with pulmonary embolism (PE). The dosing regimen may vary depending on the specific anticoagulant used. According to the 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism 1, the following recommendations can be made:

• For patients with first PE/VTE secondary to a major transient/reversible risk factor, discontinuation of therapeutic oral anticoagulation is recommended after 3 months.
• Oral anticoagulant treatment of indefinite duration is recommended for patients presenting with recurrent VTE not related to a major transient or reversible risk factor.
• If extended oral anticoagulation is decided after PE in a patient without cancer, a reduced dose of the NOACs apixaban (2.5 mg b.i.d.) or rivaroxaban (10 mg o.d.) should be considered after 6 months of therapeutic anticoagulation 1. Some key points to consider when determining the therapeutic dosing for PE include:
• The patient's bleeding risk should be assessed to identify and treat modifiable bleeding risk factors, and it may influence decision-making on the duration and regimen/dose of anticoagulant treatment 1.
• The choice of anticoagulant and dosing regimen should be individualized based on the patient's specific clinical situation and risk factors.
• Regular reassessment of the patient's drug tolerance and adherence, hepatic and renal function, and bleeding risk is recommended for patients receiving extended anticoagulation 1.

From the FDA Drug Label

1. 2 Treatment of Deep Vein Thrombosis (DVT) and/or Pulmonary Embolism (PE) EINSTEIN Deep Vein Thrombosis and EINSTEIN Pulmonary Embolism Studies XARELTO for the treatment of DVT and/or PE was studied in EINSTEIN DVT [NCT00440193] and EINSTEIN PE [NCT00439777], multi-national, open-label, non-inferiority studies comparing XARELTO (at an initial dose of 15 mg twice daily with food for the first three weeks, followed by XARELTO 20 mg once daily with food) to enoxaparin 1 mg/kg twice daily for at least five days with VKA and then continued with VKA only after the target INR (2.0–3. 0) was reached.

The therapeutic dosing for pulmonary embolism (PE) is:

• Initial dose: 15 mg twice daily with food for the first three weeks
• Maintenance dose: 20 mg once daily with food 2

From the Research

Therapeutic Dosing for Pulmonary Embolism (PE)

• The therapeutic dosing for PE involves anticoagulation, which can be achieved with various agents, including unfractionated heparin (UFH), low molecular weight heparins (LMWH), and non-vitamin K antagonist oral anticoagulants (NOACs) such as rivaroxaban 3, 4, 5, 6, 7.
• According to the 2019 guidelines of the European Society of Cardiology (ESC), all eligible patients should be treated with a NOAC in preference to a vitamin K antagonist (VKA) 3.
• 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 three months, while 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.

Anticoagulant Agents

• UFH is the drug of choice for prophylaxis and short-term treatment of PE, while oral anticoagulants are used for prophylaxis in high-risk patients and in long-term treatment of PE 4.
• LMWHs and fondaparinux are preferred over UFH in the initial anticoagulation of PE due to their lower risk of bleeding 3.
• Rivaroxaban, an oral factor Xa inhibitor, has been shown to be as effective as standard anticoagulant therapy for the treatment of deep-vein thrombosis and PE, without the need for laboratory monitoring 6.

Treatment Duration and Outcomes

• All patients with PE require therapeutic anticoagulation for at least three months 3.
• A fixed-dose regimen of rivaroxaban alone was noninferior to standard therapy for the initial and long-term treatment of PE and had a potentially improved benefit-risk profile 6.
• Treatment with rivaroxaban resulted in a shorter duration of hospitalization compared to standard therapy in patients with acute PE 7.