Suggestions for choice of anticoagulant for acute VTE treatment
| Characteristic . | Drug choice . | Rationale . |
|---|---|---|
| Extensive DVT or massive PE | Heparin | Such patients often require advanced therapy and were excluded from trials with the NOACs |
| High initial risk of bleeding | Heparin | Enables dose titration; rapid offset and availability of protamine as an antidote simplify management should bleeding occur |
| Active cancer | LMWH | No trials comparing NOACs with LMWH |
| Pregnancy | LMWH | Warfarin and NOACs cross the placenta |
| Liver dysfunction with increased prothrombin time/INR at baseline | Warfarin | Such patients were excluded from the trials because NOACs undergo hepatic metabolism |
| Unable to afford NOACs | LMWH followed by warfarin | NOACs cost less than LMWH but are more expensive than warfarin |
| Limited access to anticoagulation clinic because of impaired mobility or geographical inaccessibility | NOAC | Given in fixed doses without monitoring |
| All-oral therapy | Rivaroxaban or apixaban | Only NOACs to be evaluated in all-oral regimens |
| Creatinine clearance <30 mL/min | Warfarin | Such patients were excluded from trials with NOACs |
| Creatinine clearance 30-50 mL/min | Rivaroxaban, apixaban, or edoxaban | Less affected by renal impairment than dabigatran; if edoxaban is chosen, the 30-mg OD dose should be used |
| Dyspepsia or upper gastrointestinal symptoms | Rivaroxaban, apixaban, or edoxaban | Dyspepsia in as much as 10% given dabigatran |
| Recent gastrointestinal bleed | Apixaban | More gastrointestinal bleeding with dabigatran, rivaroxaban, and edoxaban than with warfarin |
| Recent acute coronary syndrome | Rivaroxaban, apixaban or edoxaban | Small myocardial infarction signal with dabigatran |
| Poor compliance with long-term twice-daily dosing | Rivaroxaban or edoxaban | OD regimens for long-term use |
| Characteristic . | Drug choice . | Rationale . |
|---|---|---|
| Extensive DVT or massive PE | Heparin | Such patients often require advanced therapy and were excluded from trials with the NOACs |
| High initial risk of bleeding | Heparin | Enables dose titration; rapid offset and availability of protamine as an antidote simplify management should bleeding occur |
| Active cancer | LMWH | No trials comparing NOACs with LMWH |
| Pregnancy | LMWH | Warfarin and NOACs cross the placenta |
| Liver dysfunction with increased prothrombin time/INR at baseline | Warfarin | Such patients were excluded from the trials because NOACs undergo hepatic metabolism |
| Unable to afford NOACs | LMWH followed by warfarin | NOACs cost less than LMWH but are more expensive than warfarin |
| Limited access to anticoagulation clinic because of impaired mobility or geographical inaccessibility | NOAC | Given in fixed doses without monitoring |
| All-oral therapy | Rivaroxaban or apixaban | Only NOACs to be evaluated in all-oral regimens |
| Creatinine clearance <30 mL/min | Warfarin | Such patients were excluded from trials with NOACs |
| Creatinine clearance 30-50 mL/min | Rivaroxaban, apixaban, or edoxaban | Less affected by renal impairment than dabigatran; if edoxaban is chosen, the 30-mg OD dose should be used |
| Dyspepsia or upper gastrointestinal symptoms | Rivaroxaban, apixaban, or edoxaban | Dyspepsia in as much as 10% given dabigatran |
| Recent gastrointestinal bleed | Apixaban | More gastrointestinal bleeding with dabigatran, rivaroxaban, and edoxaban than with warfarin |
| Recent acute coronary syndrome | Rivaroxaban, apixaban or edoxaban | Small myocardial infarction signal with dabigatran |
| Poor compliance with long-term twice-daily dosing | Rivaroxaban or edoxaban | OD regimens for long-term use |
OD, once daily; LMWH, low-molecular-weight heparin.