Pharmacological management of pulmonary embolism

ABSTRACT

Introduction: Pulmonary embolism (PE) is a common and potentially severe manifestation of venous thromboembolism. Its management has relied on anticoagulation by vitamin K antagonists (VKA) for the past fifty years. Recently, new alternative drugs have been developed and dramatically modified both the treatment of acute PE and its secondary prevention.

Areas covered: This review discusses the contemporary pharmacological treatment for PE, with a focus on anticoagulation options for non-high risk PE. In particular, the advent of direct oral anticoagulants (rivaroxaban, apixaban, edoxaban and dabigatran) and modalities for long-term prevention will be described. Options for anticoagulation for pregnancy-related PE are presented separately.

Expert opinion: Direct oral anticoagulants represent the first-line therapy of non-high risk PE, with better risk-benefit ratios compared with VKA due to lower bleeding risks. In specific groups of patients, however, older generations of anticoagulants such as VKA or heparins still play an important role. Multiple alternatives are available for the secondary prevention of PE, with different efficacies in reducing thrombotic risk and bleeding safety profiles.

KEYWORDS:

• pharmacological treatment
• pulmonary embolism
• review
• venous thromboembolism

Article highlights

• The management of acute PE is tailored to its predicted associated short-term mortality risk, and in the vast majority of cases relies simply on fast and efficient anticoagulation.

• DOAC have become the preferred anticoagulant agent in most situations, because of their effectiveness, favourable bleeding profile and lack of need for monitoring.

• During pregnancy, LMWHs are the preferred anticoagulant agent to treat PE.

• When secondary long-term prevention of recurrent VTE after PE is decided, the anticoagulant agent must be chosen according its efficacy and safety profile, the patient’s comorbidities and preferences.

• A specific dabigatran antidote was recently approved by the FDA. A specific anti-Xa inhibitors (-xabans, LMWH) antidote is under clinical validation.

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Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Additional information

Funding

This paper was not funded.