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Should We Now Use DOACs for PE?

August 23, 2023

Written by Carmen Wolfe

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Direct oral anticoagulants (DOACs) are safe and effective for the treatment of pulmonary embolism (PE).

Is there an echo in here?
You’ve heard it before, and this article says it again, DOACs are a great tool for treatment of PE.

Do you remember the days of warfarin clinics, INR checks, and enoxaparin bridging? With the explosion of DOACs onto the anticoagulant scene, these previous realities have become a rarity. But for the treatment of PE, are DOACs as good? Are they as safe? Many professional societies and guidelines say yes, and here’s further evidence to bolster your confidence in utilizing them.

This article summarizes a Cochrane review of ten randomized trials that evaluated DOACs (including direct thrombin inhibitors like dabigatran or factors Xa inhibitors like rivaroxaban) vs traditional anticoagulants (including heparin or vitamin k antagonists like warfarin) for treatment of imaging-confirmed PE. This meta-analysis had a total N of 13,073 and found no different in recurrent VTE (primary endpoint), all-cause mortality, or major bleeding. Authors acknowledge common limitations such as data heterogeneity, risk of bias, variation of treatment length, and wide confidence intervals due to low outcome event rates. But all in all, this is a great summary of good data that we should have confidence in using.

Authors give a big green light rating to use DOACs for PE, citing ease of use, fixed dosing, and lack of need for lab monitoring as big advantages. This study didn’t evaluate cost-effectiveness, but did highlight some general facts. The up-front cost of DOACs are higher than traditional drugs like warfarin, but the cost of INR monitoring should be considered. Similarly, reversal of DOACs is also more costly when compared to warfarin.

How will this change my practice?
I will confidently press the easy button and utilize DOACs for PE, knowing that these oral medications have equivalent risks and benefits to traditional anticoagulants.

Direct oral anticoagulants versus conventional anticoagulants for pulmonary embolism. Acad Emerg Med. 2023 Jun 26. doi: 10.1111/acem.14771. Online ahead of print.

What are your thoughts?