From the Guidelines
For managing pulmonary embolism (PE), I recommend immediate anticoagulation therapy with a direct oral anticoagulant (DOAC) such as rivaroxaban or apixaban, as they are preferred over low molecular weight heparin (LMWH) and vitamin K antagonist (VKA) regimens, unless contraindicated, as stated in the 2019 ESC guidelines 1.
Key Management Points
- Anticoagulation therapy should be initiated as soon as possible, while the diagnostic workup is ongoing, unless the patient is bleeding or has absolute contraindications, as recommended by the 2019 ESC guidelines 1.
- For hemodynamically unstable patients with high-risk PE, systemic thrombolytic therapy, surgical embolectomy, or catheter-directed treatment should be considered, taking into account the resources and expertise available at the hospital, as suggested by the 2019 ESC guidelines 1 and the 2019 ESC guidelines developed in collaboration with the European Respiratory Society (ERS) 1.
- Risk assessment is crucial in patients without haemodynamic instability, involving clinical findings, comorbidity, evaluation of the size and/or function of the right ventricle (RV), and laboratory biomarkers if appropriate, as outlined in the 2019 ESC guidelines 1.
- Treatment duration should be individualized, considering the benefits and risks of anticoagulation, and the patient's preference, with a minimum of 3 months for provoked PE and at least 6-12 months for unprovoked PE, as recommended by the 2019 ESC guidelines 1.
- Follow-up is essential to monitor for signs of venous thromboembolism (VTE) recurrence, cancer, or bleeding complications of anticoagulation, and to assess for persisting or new-onset dyspnea or functional limitation, as stated in the 2019 ESC guidelines 1.
From the FDA Drug Label
The efficacy data are provided in Table 13. Table 13. Efficacy of Fondaparinux Sodium in the Treatment of Pulmonary Embolism (All Randomized) Endpoint Fondaparinux Sodium 5,7.5, or 10 mg SC once daily N = 1,103 Heparin aPTT adjusted IV N = 1,110 n% (95% CI)n% (95% CI) Total VTE a423.8% (2.8,5.1)565. 0% (3.8,6.5) DVT only121.1% (0.6,1.9)171.5% (0.9,2.4) Non-fatal PE141.3% (0.7,2.1)242.2% (1.4,3.2) Fatal PE161.5% (0.8,2.3)151.4% (0.8,2.2) 1.3 Treatment of Pulmonary Embolism XARELTO is indicated for the treatment of pulmonary embolism (PE).
The management of Pulmonary Embolism (PE) includes treatment with:
- Fondaparinux sodium: 5,7.5, or 10 mg SC once daily, with treatment continued for at least 5 days and vitamin K antagonist therapy initiated within 72 hours after the first study drug administration and continued for 90 ± 7 days.
- Rivaroxaban (XARELTO): indicated for the treatment of pulmonary embolism (PE) 2. Key points:
- Fondaparinux sodium and heparin have similar efficacy in the treatment of PE.
- Rivaroxaban is an alternative treatment option for PE.
- Treatment should be individualized based on patient-specific factors, such as renal function and bleeding risk. 3 2
From the Research
Management of Pulmonary Embolism (PE)
The management of PE involves various treatment options, including:
- Anticoagulation therapy, which is the primary treatment for PE 4, 5, 6, 7
- Thrombolytic therapy or thrombectomy, which is recommended for high-risk patients 5
- Supportive care, including risk stratification and critical care of acute right ventricular failure 8
Anticoagulation Options
The choice of anticoagulation therapy depends on various factors, including the patient's risk factors and medical history. The options include:
- Direct oral anticoagulants (DOACs), such as rivaroxaban, apixaban, edoxaban, and dabigatran, which are preferred for non-high risk PE patients 4, 5, 6
- Vitamin K antagonists (VKAs), which are preferred for special populations, such as breastfeeding mothers, patients with end-stage renal disease, or obese patients 4
- Low-molecular-weight heparin, which is preferred for patients with high risk of bleeding or those who require closer monitoring 4, 7
- Unfractionated heparin, which is used for prophylaxis and short-term treatment of PE 7
Duration of Anticoagulation
The duration of anticoagulation therapy depends on individual risk factors and the severity of the PE. The recommendations include: