What are the recommendations for starting Acitrom (Acenocoumarol) in a patient with pulmonary thromboembolism?

Recommendations for Starting Acenocoumarol (Acitrom) in Pulmonary Thromboembolism

When initiating anticoagulation with Acenocoumarol (Acitrom) for pulmonary thromboembolism (PE), it must be overlapped with parenteral anticoagulation until an INR of 2.5 (range 2.0-3.0) has been reached. 1

Initial Risk Stratification and Treatment Selection

Before starting anticoagulation, patients should be stratified based on risk:

1. High-risk PE (with hemodynamic instability):

   • Systemic thrombolytic therapy is first-line treatment 1
   • Surgical pulmonary embolectomy if thrombolysis is contraindicated or fails 1

2. Intermediate or low-risk PE (hemodynamically stable):

   • Anticoagulation is the cornerstone of therapy 2
   • Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists like Acenocoumarol 1, 3

Acenocoumarol Protocol for PE Treatment

If using Acenocoumarol (when DOACs are contraindicated or unavailable):

1. Initial parenteral anticoagulation:

   • Start with LMWH or fondaparinux (preferred over UFH) 1
   • If using UFH, administer as continuous IV infusion with aPTT monitoring 3

2. Acenocoumarol initiation:

   • Begin Acenocoumarol alongside parenteral anticoagulation 1
   • Continue parenteral anticoagulation for at least 5 days 4
   • Continue overlapping until INR reaches 2.0-3.0 (target 2.5) 1

3. Monitoring:

   • Check INR frequently during initiation phase
   • Once stable, monitor INR regularly to maintain target range of 2.0-3.0 1

Duration of Treatment

Treatment duration depends on clinical scenario:

• First PE with major transient/reversible risk factor: 3 months 1, 3
• Unprovoked PE or persistent risk factors: Extended treatment (>3 months) 3
• Recurrent VTE: Indefinite anticoagulation 1, 3
• Antiphospholipid antibody syndrome: Indefinite treatment with VKA (not DOACs) 1

Special Considerations for Acenocoumarol

• Advantages: Potentially better stability of anticoagulant effect compared to warfarin 5
• Monitoring: Regular INR monitoring is essential
• Contraindications: Pregnancy, lactation, severe liver disease 3
• Drug interactions: Multiple drug interactions affecting INR stability

Important Caveats

• DOACs are preferred: Current guidelines recommend DOACs over VKAs like Acenocoumarol when possible 1, 3

• Specific scenarios where Acenocoumarol is indicated:

  • Severe renal impairment (CrCl <15 mL/min) 3
  • Antiphospholipid antibody syndrome 1
  • When DOACs are unavailable or contraindicated

• Regular reassessment: For patients on extended anticoagulation, regularly reassess drug tolerance, adherence, hepatic and renal function, and bleeding risk 1

• Follow-up: Routine clinical evaluation at 3-6 months after PE diagnosis to assess for signs of chronic thromboembolic pulmonary hypertension and evaluate need for extended anticoagulation 3