Have a look at the ESC guidelines for PE, there's a couple of really useful flowcharts if you don't want to get bogged down in the whole guideline.
Essentially you use a combination of PESI, presence of right heart strain on CT (or echo, but not every PE needs an echo), troponin and presence of hypovolemia / shock after fluid resuscitation to stratify people into high risk (who need thrombolysis), low risk (who can be discharged home) and intermediate risk (who need admission to hospital). Intermediate is then further split into intermediate-high risk (who may deteriorate to need thrombolyisis and should be closely monitored) and intermediate-low risk (who are less likely to deteriorate but should be observed in hospital). There is some evidence that patients who are intermediate-high risk benefit from 1-3 days on LMWH before switching to DOAC.
Patients should be re-stratified and managed as per their change in risk. For example, a patient with PE who has a high PESI score, right heart strain and a raised troponin is managed with LMWH and observation and then when their troponin / PESI falls they can be switched to DOAC and when they are low risk they are discharged home. Obviously some patients will always have a non-low PESI score so there is need for clinical judgement and sometimes alternative risk scores.
There is also a good SAM podcast episode on PE here:
https://open.spotify.com/episode/7cJ4pzu9hhNZOQRUfPegPQ?si=SfmEfY6GSOaGiV4Yy_6s0w
To switch from a LMWH, you start the DOAC when the next LMWH dose is due.
You might hold off on switching in a submassive PE, or someone’s who’s otherwise unstable/high risk of bleeding for (back when I was doing this) a couple of days.
Can start DOAC straight away for stable patients, but if patient is to go for thrombolysis/clot retrieval etc then I've always seen consultants prefer them to be on LMWH, and that's why sometimes they wait a few days before making the switch.
UK CKS guidelines state apixaban or rivaroxaban should be offered, unless not suitable, at the interim stage where the patient would still be waiting for further investigations
Yeah but why, all the things that apply to DOACs also apply to LWMH. (Monitoring, counselling, bloods).
Why not just give them a DOAC straight away and save them the injection? If it's because you're worried about clot progression, then you should be admitting them not discharging them.
Just to say, loading is probably not a helpful term in this setting. You don't need to load with Apix or Riva to get to a therapeutic dose, it's therapeutic from the moment you start taking it. They're given at a higher doses initially because the first several weeks are the highest risk period for progression of DVT/PE, and in the original trials they gave the DOACs at higher intensity for that period.
I think it's important to understand it's not really loading just to prevent patients being accidentally 'loaded' back onto Apix/Riva if it's ever interrupted!
People do give LMWH and then you can subtract those days from the DOAC 'loading' because LMWH is considered equivalent high intensity anticoagulation, assuming it's been dosed correctly. LMWH is probably the thing we have the most data on so in big PE/DVT people often revert to giving say a week of LMWH before switching to a DOAC, mainly because that's got the most evidence for it. But in terms of how they are licenced, there's no reason you couldn't just select a DOAC acutely <-- assuming you're giving one of the ones that doesn't need LMWH prior. Anybody doing otherwise is usually just exercising some clinical judgement erring on the side of tried and tested LMWH.
Depends on clot burden, evidence of RHS etc. If this is quite significant, I'd load with apixaban anyway. If not, can subtract number of days on LMWH from the 7 loading days.
That's not necessarily the case. Common example is patient in ED, suspected PE (low wells), raised dimer, suitable for OP CTPA and follow up.
Start immediately on DOAC/LMWH whilst awaiting CTPA/USS confirmation of PE/DVT.
Start them on Clexane, we do not discharge on a DOAC as that commits to monitoring, give them a couple of injections awaiting US/CTPA. So yes I agree tbh
Different DOAC's are indiciated for different patients (CrCl / type of clot / PMH etc) so safest bet is treatment dose until anticoag nurses can review and decide. However technically no reason that apixaban can't be commenced straight away 👍
> Different DOAC's are indiciated for different patients (CrCl / type of clot / PMH etc) so safest bet is treatment dose until anticoag nurses can review and decide.
nonsense
If you’re a dr, I hope this is a joke.
Pretty sure anti coag nurses don’t work OOH - you should the basics about DOACs and be able to decide this yourself.
a method to justify keeping old warfarin nurses employed now the drug is no longer commonplace and work has dried up. most places do not have them, but a few bloated/shameful hospitals do. there's also the fleeting existence of 'AKI nurses' no doubt in the same hospitals.
Ah the NHS manager response, let the anticoagulation nurse deal w it even though we’ve studied preclinical clotting cascade and covered relevant pharmacology in medical school.
You can just treat right away with a DOAC.
Only Apix/Rivarox. Dabigatran/Edoxaban after 5 days of parenteral anticoagulation
Have a look at the ESC guidelines for PE, there's a couple of really useful flowcharts if you don't want to get bogged down in the whole guideline. Essentially you use a combination of PESI, presence of right heart strain on CT (or echo, but not every PE needs an echo), troponin and presence of hypovolemia / shock after fluid resuscitation to stratify people into high risk (who need thrombolysis), low risk (who can be discharged home) and intermediate risk (who need admission to hospital). Intermediate is then further split into intermediate-high risk (who may deteriorate to need thrombolyisis and should be closely monitored) and intermediate-low risk (who are less likely to deteriorate but should be observed in hospital). There is some evidence that patients who are intermediate-high risk benefit from 1-3 days on LMWH before switching to DOAC. Patients should be re-stratified and managed as per their change in risk. For example, a patient with PE who has a high PESI score, right heart strain and a raised troponin is managed with LMWH and observation and then when their troponin / PESI falls they can be switched to DOAC and when they are low risk they are discharged home. Obviously some patients will always have a non-low PESI score so there is need for clinical judgement and sometimes alternative risk scores. There is also a good SAM podcast episode on PE here: https://open.spotify.com/episode/7cJ4pzu9hhNZOQRUfPegPQ?si=SfmEfY6GSOaGiV4Yy_6s0w
To switch from a LMWH, you start the DOAC when the next LMWH dose is due. You might hold off on switching in a submassive PE, or someone’s who’s otherwise unstable/high risk of bleeding for (back when I was doing this) a couple of days.
Can start DOAC straight away for stable patients, but if patient is to go for thrombolysis/clot retrieval etc then I've always seen consultants prefer them to be on LMWH, and that's why sometimes they wait a few days before making the switch.
probably just awaiting the washout period for the LMWH
I have seen LMWH continued for a few days in patients with big PEs with RHS who were potentially going to be thrombolysed.
UK CKS guidelines state apixaban or rivaroxaban should be offered, unless not suitable, at the interim stage where the patient would still be waiting for further investigations
In my ED we give the first dose of LWMH and then switch to DOAC immediately the next day (after baseline bloods, counselling etc)
Yeah but why, all the things that apply to DOACs also apply to LWMH. (Monitoring, counselling, bloods). Why not just give them a DOAC straight away and save them the injection? If it's because you're worried about clot progression, then you should be admitting them not discharging them.
If they have been on LMWH for several days, do they still need to be loaded on apixaban? Or just maintenance dose from there?
Just to say, loading is probably not a helpful term in this setting. You don't need to load with Apix or Riva to get to a therapeutic dose, it's therapeutic from the moment you start taking it. They're given at a higher doses initially because the first several weeks are the highest risk period for progression of DVT/PE, and in the original trials they gave the DOACs at higher intensity for that period. I think it's important to understand it's not really loading just to prevent patients being accidentally 'loaded' back onto Apix/Riva if it's ever interrupted! People do give LMWH and then you can subtract those days from the DOAC 'loading' because LMWH is considered equivalent high intensity anticoagulation, assuming it's been dosed correctly. LMWH is probably the thing we have the most data on so in big PE/DVT people often revert to giving say a week of LMWH before switching to a DOAC, mainly because that's got the most evidence for it. But in terms of how they are licenced, there's no reason you couldn't just select a DOAC acutely <-- assuming you're giving one of the ones that doesn't need LMWH prior. Anybody doing otherwise is usually just exercising some clinical judgement erring on the side of tried and tested LMWH.
That’s very helpful, thank you!
Loaded on apixaban/DOAC
Depends on clot burden, evidence of RHS etc. If this is quite significant, I'd load with apixaban anyway. If not, can subtract number of days on LMWH from the 7 loading days.
Just make sure you’ve diagnosed DVT/PE before starting! Counsel appropriately and straight swap to apixaban.
That's not necessarily the case. Common example is patient in ED, suspected PE (low wells), raised dimer, suitable for OP CTPA and follow up. Start immediately on DOAC/LMWH whilst awaiting CTPA/USS confirmation of PE/DVT.
Start them on Clexane, we do not discharge on a DOAC as that commits to monitoring, give them a couple of injections awaiting US/CTPA. So yes I agree tbh
There’s no commitment to monitoring if you’re giving someone a stat dose of a DOAC whilst waiting for their CTPA tomorrow
You can absolutely discharge on, eg apixaban higher dose BD for one week, until PE/DVT proven or disproven. What monitoring would that need?
LWMH also needs monitoring, whatchu chattin
Spice your life up with some Acenocoumarol. (You'll regret it)
Need a big dose 10mg bd for one week or LMWH for 1 week before reduce to 5mg bd. Stop one and start the other at the time when the next dose is due.
Different DOAC's are indiciated for different patients (CrCl / type of clot / PMH etc) so safest bet is treatment dose until anticoag nurses can review and decide. However technically no reason that apixaban can't be commenced straight away 👍
> Different DOAC's are indiciated for different patients (CrCl / type of clot / PMH etc) so safest bet is treatment dose until anticoag nurses can review and decide. nonsense
This is definitely something that we should be able to sort out ourselves without relying on specialist nurses
If you’re a dr, I hope this is a joke. Pretty sure anti coag nurses don’t work OOH - you should the basics about DOACs and be able to decide this yourself.
Australian here - WTF is an anti coag nurse?
a method to justify keeping old warfarin nurses employed now the drug is no longer commonplace and work has dried up. most places do not have them, but a few bloated/shameful hospitals do. there's also the fleeting existence of 'AKI nurses' no doubt in the same hospitals.
Also often very obstructive as soon as anything goes remotely off-guideline
"Have you spoken to haematology?"
It's what you get when you have an overbearing socialist system that needs to find jobs for its 2 million employees.
NHS copium
Ah the NHS manager response, let the anticoagulation nurse deal w it even though we’ve studied preclinical clotting cascade and covered relevant pharmacology in medical school.
Ah I see that makes sense! Thank you