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Treatment of VTE and prevention of recurrent VTE depends on local policy. One approach is the administration of LMWH concurrently with a VKA for at least 5 days, followed by VKA on its own once the INR is at least 2.1 However, DOACs have emerged as valid options to treat VTE1 and are increasingly being used in clinical practice,2 due to their stable therapeutic effect, reduced interactions with other medications and food, and reduced need for regular monitoring.3
DOACs have been shown to reduce the treatment burden compared with VKAs, including by offering shorter time to discharge from hospital in acute VTE.4,5 Patients receiving DOACs to treat DVT / PE have also reported higher treatment satisfaction compared with those on VKA.6-9
Watch the video below for a discussion by Dr Ander Cohen on the updated 2020 NICE guideline recommendations for the use of DOACs for the initial treatment of appropriate patients with confirmed DVT or PE.
Please refer to the individual DOAC SmPCs for full dosing recommendations.
* Short duration of therapy (at least 3 months) should be based on transient risk factors (e.g. recent surgery, trauma, immobilisation). The duration of overall therapy should be individualised after careful assessment of the treatment against the risk for bleeding.10-13
† 150 mg or 110 mg should be selected based on an individual assessment of the thromboembolic risk and risk of bleeding.12
[References for image: 10. Apixaban Summary of Product Characteristics. 11. Rivaroxaban Summary of Product Characteristics. 12. Dabigatran Summary of Product Characteristics. 13. Edoxaban Summary of Product Characteristics.]
Alongside the decision to use a single-drug approach with rivaroxaban or apixaban, or a DOAC that requires initial treatment with LMWH like dabigatran or edoxaban, there are other considerations when selecting a DOAC for your patient with VTE, such as contraindications or the dosing regimen. As patients should be actively involved in the decision-making process, it is important to provide information on all relevant treatment options, including the benefits, risks and potential consequences, and to consider patient preference.15
For full contraindications please refer to individual product prescribing information.
The efficacy and safety of DOACs for the treatment of VTE and prevention of recurrent VTE have been assessed in randomised controlled trials. The results of key clinical trials investigating the DOACs shown below provide an overview of the efficacy and safety profiles of DOACs vs. LMWH/warfarin in the treatment of VTE.16-19
It should be noted that there are no head-to-head randomised clinical trials comparing the DOACs, and comparisons cannot be made between individual DOACs based on these data. Please refer to the individual SmPCs for further information.10-14
* Duration of treatment was determined by the treating physician before randomisation. Most patients received 6 or 12 months of therapy, or both.11
† Patients with body weight ≤60 kg or CrCl 30–50 ml/min, or patients receiving concomitant potent P-gp inhibitors received edoxaban 30 mg OD.16,21
*The primary efficacy endpoint was the incidence of the adjudicated composite of recurrent symptomatic VTE or death related to VTE.17 Recurrent VTE included fatal or non-fatal PE and DVT.17
References: 10. ELIQUIS (apixaban) summary of Product Characteristics. 17. Agnelli G et al. N Engl J Med 2013; 369: 799-808.
*The primary efficacy endpoint was symptomatic recurrent VTE defined as the composite of recurrent DVT or fatal or non-fatal PE.11
References: 11. Rivaroxaban Summary of Product Characteristics. 20. Prins MH et al. Thrombosis Journal 2013; 11: 21.
There are no head-to-head randomised clinical trials comparing the DOACs. Comparisons cannot be made between individual DOACs based on these data.
BD=Twice Daily CrCl=Creatinine Clearance DOAC=Direct-acting Oral Anticoagulant DVT=Deep Vein Thrombosis HCP=Health Care Professional INR=International Normalised Ratio LMWH=Low Molecular Weight Heparin MHRA=Medicines and Healthcare products and Regulatory Agency OD=Once Daily PE=Pulmonary Embolism P-gp=P-glycoprotein smPC=Summary of Product Characteristics UFH=Unfractionated Heparin VKA=Vitamin K Antagonist VTE=Venous Thromboembolism