Recommended DOAC Dosing Regimens for Pulmonary Embolism Treatment
For the treatment of pulmonary embolism, the recommended DOAC dosing regimens are: apixaban 10 mg twice daily for 7 days followed by 5 mg twice daily, or rivaroxaban 15 mg twice daily for 21 days followed by 20 mg once daily. 1, 2, 3
Initial Treatment Phase Dosing
Apixaban
Rivaroxaban
Dabigatran
- Initial phase: Requires 5-10 days of parenteral anticoagulation first 1
- Maintenance phase: 150 mg twice daily 1
Edoxaban
- Initial phase: Requires at least 5 days of parenteral anticoagulation first 1
- Maintenance phase: 60 mg once daily (30 mg once daily if CrCl 30-50 mL/min or body weight <60 kg) 1
Duration of Treatment
The European Society of Cardiology recommends:
- Minimum 3 months of therapeutic anticoagulation for all PE patients 4
- For PE secondary to a major transient/reversible risk factor: discontinue after 3 months 4
- For unprovoked PE or persistent risk factors: extended anticoagulation (>3 months) should be considered 4
- For recurrent VTE: indefinite anticoagulation is recommended 4
Extended Treatment Phase Dosing
For patients requiring extended anticoagulation beyond 6 months:
- Apixaban: Reduce to 2.5 mg twice daily 4, 1
- Rivaroxaban: Reduce to 10 mg once daily 4, 1
- Dabigatran and Edoxaban: Maintain the same dose as maintenance phase 4
Special Populations
Renal Impairment
- For severe renal impairment (CrCl <30 mL/min): Unfractionated heparin followed by vitamin K antagonist is preferred 1
- Apixaban dose reduction to 2.5 mg twice daily if patient has at least two of: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 2
Cancer Patients
- Low Molecular Weight Heparin (LMWH) is traditionally preferred for at least 6 months 1
- Edoxaban or rivaroxaban may be considered as alternatives to LMWH 4
Pregnancy
- DOACs are contraindicated; LMWH is the treatment of choice 1
Antiphospholipid Syndrome
Practical Considerations
- Single DOAC regimen is preferred in a treatment pathway to minimize confusion over dosing 4
- DOACs are associated with shorter hospital length of stay compared to traditional therapy 4, 5
- DOACs can be used for suspected PE pending diagnosis as an alternative to LMWH 4
- For temporary interruption for surgery, discontinue apixaban at least 48 hours and rivaroxaban at least 24 hours prior to procedures with moderate/high bleeding risk 2, 3
Cautions and Monitoring
- Regular clinical follow-up at 3-6 months is essential to assess medication adherence, bleeding complications, and need for extended anticoagulation 1
- Avoid combined P-gp and strong CYP3A4 inhibitors with DOACs, or reduce dose appropriately 2, 3
- Premature discontinuation increases thrombotic risk; consider bridging with another anticoagulant if stopping for reasons other than bleeding 2, 3
The British Thoracic Society and European Society of Cardiology guidelines both support the use of DOACs as first-line therapy for PE, with evidence showing they are non-inferior to traditional therapy with lower bleeding risk 4.