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Patients with DVT / PE should be offered treatment with an anticoagulant.1 Conventional treatment consists of a parenteral anticoagulant, such as enoxaparin, for at least 5 days given concurrently with warfarin, followed by warfarin for at least 3 months.2 However, four DOACs3-6, apixaban, dabigatran, edoxaban and rivaroxaban, have been approved for the treatment of DVT / PE and the prevention of recurrent DVT / PE in adults. Dabigatran and edoxaban should be administered following initial use of parenteral anticoagulant for at least 5 days.4,5 The DOACs are recommended, within their marketing authorisations, as first line by NICE7-12 and have been accepted for use by the Scottish Medicines Consortium (SMC).13-16
Offer either apixaban or rivaroxaban to people with confirmed proximal DVT or PE (but see recommendations for people with any of the clinical features listed in 1.3.7).1*
If neither apixaban nor rivaroxaban is suitable offer:1
* NICE NG158: When offering anticoagulation treatment, take into account comorbidities, contraindications and the person’s preferences. Clinical features listed in 18.104.22.168
See full guidance for further details.
-NICE NG158, 2020
Consider outpatient treatment for suspected or confirmed low-risk PE, using a validated risk stratification tool to determine the suitability of outpatient treatment. When offering outpatient treatment to people with suspected PE, follow the NICE recommendations 1.1.15 to 1.1.21 on diagnosis and initial management.1
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.
NICE NG158: Anticoagulation treatment for confirmed DVT or PE1
1.3.5: For people with confirmed proximal DVT or PE, offer anticoagulation treatment for at least 3 months
1.3.7: When offering anticoagulation treatment for confirmed proximal DVT or PE, take into account comorbidities, contraindications and the person’s preferences
1.3.8: Offer either apixaban or rivaroxaban to people with confirmed proximal DVT or PE unless they have one of the comorbidities listed below:
* As per available medical guidelines, short duration of treatment (at least 3 months) should be based on transient risk factors, (e.g. recent surgery, trauma, immobilisation).3 The duration of overall therapy should be individualised after careful assessment of the treatment benefit against the risk for bleeding.1,3
When prevention of recurrent DVT / PE is indicated, the 2.5 mg twice-daily dose should be initiated following completion of 6 months of treatment with apixaban 5 mg twice daily or with another anticoagulant.3
Not all patients who start on apixaban for acute DVT / PE will stay on apixaban; some acute DVT / PE patients who receive treatment do not require treatment for the prevention of recurrent DVT / PE. Other patients may be prescribed apixaban for the prevention of recurrent VTE after initial treatment for acute DVT / PE with another anticoagulant.3 This is a decision for the prescribing clinician together with patient involvement in the decision-making.
† Patients with active cancer can be at high risk of both venous thromboembolism and bleeding events. When apixaban is considered for DVT or PE treatment in cancer patients, a careful assessment of the benefits against the risks should be made.3
Agree a plan for monitoring and follow-up with people having outpatient anticoagulant treatment for suspected or confirmed low-risk PE. Give them1:
ARR=Absolute Risk Reduction BD=Twice Daily CRNM=Clinically Relevant Non-Major DOAC=Direct-acting Oral Anticoagulant DVT=Deep Vein Thrombosis INR=International Normalised Ratio ITT=Intention-To-Treat LMWH=Low Molecular Weight Heparin MHRA=Medicines and Healthcare products and Regulatory Agency NICE=National Institute for Health and Care Excellence PE=Pulmonary Embolism RR=Relative Risk RRR=Relative Risk Reduction SMC=Scottish Medicines Consortium smPC=Summary of Product Characteristics VKA=Vitamin K Antagonist VTE=Venous Thromboembolism