Direct oral anticoagulants in the treatment of pulmonary embolism

Abstract

Objective: The objective of this review is to examine the management strategies for pulmonary embolism (PE) with an emphasis of the role of direct oral anticoagulants (DOACs).

Methods: PubMed was searched to identify relevant journal articles published through April 2017. Additional references were obtained from articles discovered during the database search.

Results: Initial heparinization followed by long-term anticoagulation with vitamin K antagonists has been considered the mainstay for the treatment of PE. However, DOACs now offer comparably effective and potentially safer alternatives for both acute and long-term treatment of PE using a monotherapy approach without the need for initial heparinization for rivaroxaban or apixaban. Advantages to using DOACs include oral availability, rapid onset of action, minimal drug and food interactions, predictable pharmacokinetics, and lack of need for routine monitoring. Limitations of using these agents include a limited availability of assays to quickly and efficiently measure their anticoagulant effects and the lack of widely available reversal agents for the direct oral factor Xa inhibitors; although idarucizumab has recently been approved for the reversal of dabigatran’s anticoagulant effects.

Conclusions: Advantages to using DOACs render them an attractive alternative to conventional therapy in PE treatment that may simplify acute and long-term treatment paradigms, improve patient outcomes, and increase patient compliance. However, questions remain pertaining to the use of DOACs in PE patients with high-risk features and in cancer patients and fragile populations. Clinical studies are under way to address many of these issues.

Keywords:

• Pulmonary embolism
• deep vein thrombosis
• venous thromboembolism
• direct oral anticoagulants
• treatment

Transparency

Declaration of funding

Medical writing and editorial support for this review was funded by Daiichi Sankyo Inc., Basking Ridge, NJ, USA.

Author contributions: Both authors made substantial intellectual contributions to the conception and design of this review. Both were involved in drafting of the manuscript and revising it critically for important intellectual content and both approved the final manuscript.

Declaration of financial/other relationships

A.C.S. has disclosed that he has served as a consultant for Boehringer Ingelheim, Janssen, Bayer Healthcare, and Daiichi Sankyo; and has served on advisory committees for Bristol-Myers Squibb, Pfizer, Janssen, Portola, and Bayer Healthcare. J.B.E. has disclosed that she has no significant relationships with or financial interests in any commercial companies related to this study or article.

CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgements

Medical writing and editorial support was provided by Senem Kurtoglu PhD of AlphaBioCom LLC, King of Prussia, PA, USA.