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Home | Articles | Cardiac | Anticoagulation for AF, DVT and PE

Anticoagulation for AF, DVT and PE

Last updated 18th March 2024

Choice of DOAC

  1. We used to recommend edoxaban for AF and apixaban for VTE but as of January 2024, apixaban is recommended for all indications that require a DOAC.

Dosing is Important

  1. It is vital to prescribe the appropriate dose for patients.
  2. Prescribing too low a dose puts the patient at risk of embolic complications, prescribing too high a dose puts the patient at risk of significant bleed

Anticoagulation for Atrial Fibrillation (AF) and Atrial Flutter

  1. Apixaban is indicated for paroxysmal and persistent AF and atrial flutter provided the patient does not have severe mitral stenosis or a mechanical heart valve, after estimating benefits and risks using the CHA2DS2VASc score.
  2. Generally speaking benefits outweigh risks when CHA2DS2VASc score ≥1 in men and ≥2 in women
  3. The usual dose of apixaban for AF and flutter is 5mg bd
  4. If at least two out of the following three criteria are met, then the dose is 2.5mg twice daily:
    • Age 80 years or over
    • Body weight less than 61kg
    • Creatinine 133 micromol/L or over
  5. If creatinine clearance is 15 – 29ml/min, then the dose is 2.5mg twice daily

Anticoagulation for VTE

  1. Apixaban is our first line oral anticoagulant for the treatment of clinically suspected or confirmed VTE.  Apixaban can be started immediately and continued once VTE has been confirmed.
  2. There is no need to use dalteparin in the run up to VTE confirmation unless the patient is unstable or apixaban is contraindicated for that patient.
  3. Do not use apixaban if creatinine clearance is <15ml/min. Use with caution if creatinine clearance is between 15 and 29ml/min.
  4. The dose of apixaban for treatment of VTE is 10mg twice daily for 7 days, reducing to 5mg twice daily for the duration of treatment (up to 6 months). Please specify duration of treatment.
  5. If a decision is made to anticoagulate the patient for longer than 6 months in order to prevent recurrence of VTE, then the dose should be reduced to 2.5mg twice daily.

Dalteparin Dosing

Patient's Weight (kg)Dose
<467,500 units daily
46-5610,000 units daily
57-6812,500 units daily
69-8215,000 units daily
>8218,000 units daily

Second Line Edoxaban for AF, DVT and PE

  1. Consider edoxaban as a second line choice it, for example, a patient might struggle with twice daily medication.
  2. Dose of edoxaban varies by weight and renal function
  3. You must calculate creatinine clearance using the Cockcroft Gault equation either manually or using an app such as MDCalc – Creatinine Clearance Calculator. Do not use eGFR. Use actual body weight for the calculation.
Creatinine ClearanceDose if patient weight 60kg or lessDose if patient weight 61kg or moreDose if patient also taking ciclosporin, dronedarone, erythromycin, ketoconazole
<15 ml/minAvoidAvoidAvoid
15-49 ml/min30mg daily30mg dailyAvoid
50-100 ml/min30mg daily60mg daily30mg daily
100 ml/minAvoidAvoidAvoid

Extremes of Body Weight

  1. Patients at extremes of body weight were not excluded from the trials and subset analysis from these trials does not suggest there is any difference in outcome in these patients.
  2. Our advice is to prescribe apixaban for these patients, using the doses recommended above.
  3. Some clinicians may prefer to use warfarin in these circumstances, so best to check with the consultant in charge of the case.

Patients with Malignancies

  1. If it is appropriate to anticoagulate the patient, then apixaban can be used at the licensed doses.
  2. Seek specialist advice before prescribing. More information available via OOQS.

Patients Taking Antiplatelets

  1. As a general rule, stop antiplatelets when the decision to prescribe anticoagulants is made.
  2. In most cases the concomitant prescribing of antiplatelets and anticoagulants increases the risk of significant bleed without reducing cardiovascular risk. However, there will be exceptions to this – for example, recent MI.
  3. Discuss with the appropriate specialist if in doubt.

Renal Function

  1. Creatinine clearance should be calculated based on actual body weight.
  2. Check creatinine clearance annually, or more often if clinically appropriate due to deteriorating renal function. For example if CrCl 15-30ml/min recheck 3 monthly and 30-50ml/min recheck 6 monthly.

Falls Risk

  1. Many patients are not anticoagulated adequately due to their risk of falls and potential bleeds.
  2. Where possible, discuss the risks and benefits of anticoagulation with patients and their family/carers so that informed choices can be made.
  3. Calculate CHA2DS2VASc scores to aid decision making.
  4. If the decision is made to anticoagulate, DO NOT reduce the dose due to an increased falls risk – this merely results in ineffective anticoagulation whilst still putting the patient at risk of a significant bleed.

Contraindications

  1. This list is not exclusive, please check the BNF or SPC for up to date prescribing information.
  2. Avoid apixaban if any of the following present:
    • Replacement mechanical heart valves
    • Moderate-severe mitral stenosis
    • Antiphospholipid syndrome
    • Pregnant breastfeeding or planning a pregnancy
    • Liver disease associated with cirrhosis and/or coagulopathy
    • Uncontrolled severe hypertension
    • Concomitant treatment with any other anticoagulants e.g. warfarin, UFH or LMWH
    • Lesion or condition, if considered to be a significant risk for major bleeding e.g. recent GI bleed
    • Patients pre or post VTE thrombolysis

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Updated by Alison Moore and Chris Isles