• Offer non-pregnant/not breastfeeding patients with confirmed PE treatment with apixaban or rivaroxaban - see below for doses and check BNF
  
  • if body weight >120 kg or BMI >40 kg/m², prefer rivaroxaban 
  • if aged >70 yr, frailty, creatinine clearance using actual body weight <50 mL/min or GI bleeding history/risk factors, prefer apixaban
  • if pre-menopausal favour apixaban
  • if creatinine clearance using actual body weight 15-30 mL/min and/or body weight <60 kg, prefer edoxaban 30 mg once daily
  • refer to individual DOAC SPC and BNF for further dosing advice

Creatinine clearance using actual body weight

Creatinine clearance= 

• Females:
  

  CrCl =	1.04 x (140 - age) x body weight* (kg)
  	Serum creatinine (µmol/L)

• Males:
  

  CrCl =	1.23 x (140 - age) x body weight* (kg)
  	Serum creatinine (µmol/L)

* Body weight = Actual body weight

• DOACs are contraindicated in pregnancy and breastfeeding
• If known antiphospholipid syndrome, metallic heart valve or moderate-severe mitral stenosis, avoid
  • if CrCl <15 mL/min, contraindicated
• Consider renal dose LMWH and initiate warfarin
• If CrCl <30 mL/min, discuss with haematologist 
• If previous bariatric surgery, DOAC absorption may be significantly reduced, discuss with haematologist
• Dabigatran contraindicated in patients using dosette boxes for medicines

Apixaban

Initial treatment

• 10 mg 12-hrly for 7 days

Maintenance therapy up to first 6 months

• 5 mg 12-hrly

Extended treatment (after first 6 months)

• 2.5 mg 12-hrly

Rivaroxaban

Initial treatment

• 15 mg 12-hrly for 21 days with food

Maintenance therapy up to first 6 months

• 20 mg once daily with food

Extended treatment (after first 6 months)

• 20 mg once daily or 10 mg once daily with food (discuss with haematology – STAC)

Edoxaban

Initial treatment

• 5 days of therapeutic LMWH - must not be given concurrently with edoxaban

Maintenance therapy up to first 6 months

• 60 mg once daily

Extended treatment (after first 6 months)

• 60 mg once daily

Dabigatran

Initial treatment

• 5 days of therapeutic LMWH - must not be given concurrently with dabigatran

Maintenance therapy up to first 6 months

• 150 mg 12-hrly

Extended treatment (after first 6 months)

• 150 mg 12-hrly