What is the recommended dose of Direct Oral Anticoagulants (DOACs) for the treatment of Deep Vein Thrombosis (DVT)?

DOAC Dosing for DVT Treatment

For acute DVT treatment, use rivaroxaban 15 mg twice daily with food for 21 days, then 20 mg once daily with food; OR apixaban 10 mg twice daily for 7 days, then 5 mg twice daily; OR edoxaban 60 mg once daily (after 5-10 days of parenteral anticoagulation); OR dabigatran 150 mg twice daily (after 5-10 days of parenteral anticoagulation). 1, 2

Initial Treatment Phase Dosing

Rivaroxaban (Preferred - No Lead-in Required)

• 15 mg orally twice daily with food for the first 21 days 1
• Then 20 mg once daily with food for remaining treatment 1
• No parenteral anticoagulation bridge needed 1

Apixaban (Preferred - No Lead-in Required)

• 10 mg orally twice daily for 7 days 2
• Then 5 mg twice daily for remaining treatment 2
• No parenteral anticoagulation bridge needed 2

Edoxaban (Requires Lead-in)

• Requires 5-10 days of parenteral anticoagulation (LMWH or UFH) first 3
• Then 60 mg once daily 3

Dabigatran (Requires Lead-in)

• Requires 5-10 days of parenteral anticoagulation first 3
• Then 150 mg twice daily 3

Treatment Duration

Minimum 3 months of anticoagulation for all acute DVT 3

Provoked DVT (Surgery or Major Transient Risk Factor)

• 3 months total, then stop 3
• No extended-phase therapy recommended 3

Unprovoked DVT or Persistent Risk Factors

• Minimum 3 months, then continue indefinitely with extended-phase dosing 3
• Extended-phase options after initial 3-6 months:
  • Rivaroxaban 20 mg daily OR 10 mg daily 3, 1
  • Apixaban 5 mg twice daily OR 2.5 mg twice daily 3, 2

Special Populations

Cancer-Associated DVT

• Prefer oral factor Xa inhibitors (apixaban, rivaroxaban, edoxaban) over LMWH 3
• Use apixaban or LMWH for luminal GI malignancies (rivaroxaban and edoxaban have higher GI bleeding risk) 3
• Continue anticoagulation as long as cancer is active 3

Renal Impairment (CrCl <30 mL/min)

• Avoid standard DOAC dosing 3
• Consider dose-adjusted warfarin or alternative anticoagulation 3

Antiphospholipid Syndrome

• Use warfarin (target INR 2.5) instead of DOACs 3
• DOACs associated with increased thrombotic risk in triple-positive APS 3

Moderate-Severe Liver Disease

• Avoid DOACs 3
• Use alternative anticoagulation 3

Critical Dosing Considerations

All DOACs are preferred over warfarin for standard DVT treatment 3

Food requirements differ by agent:

• Rivaroxaban 15 mg and 20 mg doses MUST be taken with food 1
• Apixaban, edoxaban, dabigatran can be taken with or without food 2

No routine laboratory monitoring required 4

Avoid combining DOACs with other anticoagulants 1, 2

Do not use bridging with LMWH when starting rivaroxaban or apixaban - this increases bleeding risk without benefit 4

Common Pitfalls to Avoid

Never use the maintenance dose during the initial treatment phase - rivaroxaban 15 mg BID and apixaban 10 mg BID are essential for adequate initial anticoagulation 1, 2

Never forget food requirement for rivaroxaban 15 mg and 20 mg doses - absorption is significantly reduced without food 1

Never use DOACs in severe renal impairment (CrCl <30 mL/min) without dose adjustment or alternative selection 3

Never use DOACs as first-line in confirmed antiphospholipid syndrome - warfarin is superior 3

Never discontinue DOACs abruptly without alternative anticoagulation if ongoing indication exists - this increases thrombotic risk 1, 2