How long do you anticoagulate a patient with Pulmonary Embolism (PE)?

From the Guidelines

Therapeutic anticoagulation for more than 3 months is recommended for all patients with pulmonary embolism (PE). The duration of anticoagulation depends on several factors, including the presence of transient or reversible risk factors, recurrent VTE, and antiphospholipid antibody syndrome.

Key Considerations

• For patients with first PE/VTE secondary to a major transient/reversible risk factor, discontinuation of therapeutic oral anticoagulation is recommended after 3 months 1.
• For patients presenting with recurrent VTE not related to a major transient or reversible risk factor, oral anticoagulant treatment of indefinite duration is recommended 1.
• For patients with antiphospholipid antibody syndrome, oral anticoagulant treatment with a VKA for an indefinite period is recommended 1.

Extended Anticoagulation

• Extended oral anticoagulation of indefinite duration should be considered for patients with a first episode of PE and no identifiable risk factor 1.
• Extended oral anticoagulation of indefinite duration should be considered for patients with a first episode of PE associated with a persistent risk factor other than antiphospholipid antibody syndrome 1.
• 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.

Monitoring and Reassessment

• In patients who receive extended anticoagulation, their drug tolerance and adherence, hepatic and renal function, and bleeding risk should be reassessed at regular intervals 1.

From the FDA Drug Label

Patients with an objectively confirmed symptomatic DVT and/or PE were randomized to treatment with apixaban 10 mg twice daily orally for 7 days followed by apixaban 5 mg twice daily orally for 6 months The patient with PE should be anticoagulated for 6 months 2.

From the Research

Anticoagulation Duration for Patients with Pulmonary Embolism

The duration of anticoagulation for patients with pulmonary embolism (PE) is a critical aspect of treatment. According to current guidelines and studies, the following points should be considered:

• The optimal duration of anticoagulation after a first episode of PE remains controversial and should be made on an individual basis, balancing the estimated risk for recurrence without anticoagulant treatment against bleeding risk under anticoagulation 3.
• Current recommendations on duration of anticoagulation are based on a 3% per year risk of major bleeding expected during long-term warfarin treatment 3.
• Anticoagulant therapy should be discontinued after the initial 3 to 6 months in those patients who had the first episode in association with temporary risk factors 3, 4.
• Patients with a first unprovoked event and an estimated low risk for bleeding complications should be evaluated for indefinite treatment on an individualized basis 3.
• The duration of anticoagulation may be modulated according to the presence or absence of certain additional risk factors, such as major thrombophilia, chronic pulmonary hypertension, or massive pulmonary embolism 4.

Special Considerations

Some special situations require consideration when determining the duration of anticoagulation:

• Active cancer and pregnancy require long-term use of low-molecular-weight or unfractionated heparin 5.
• Cancer-associated thromboembolism (CAT) may require the use of low molecular weight heparin (LMWH) for 3-6 months, or factor Xa inhibitors, depending on the specific situation 6.
• Obese patients up to 150 kg can be treated with standard doses of rivaroxaban and apixaban 6.

General Recommendations

General recommendations for anticoagulation duration include:

• A minimum of three months of anticoagulation for most patients with PE 5, 6.
• Anticoagulation for 3-6 months for patients with VTE, while the duration of subsequent secondary prophylaxis depends on the presumed risk of VTE recurrence and bleeding 6.
• Individualized decision-making based on a risk/benefit analysis for anticoagulation beyond three months 5, 3.