Venous Thromboembolism (VTE) Medication

Updated: Nov 05, 2020
  • Author: Vera A De Palo, MD, MBA, FCCP; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
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Medication

Medication Summary

Anticoagulant inpatient medications should include heparin or a low-molecular-weight heparin (LMWH), followed by the initiation of an oral coumarin derivative. Heparin is administered by bolus dosing, followed by a continuous infusion. The predominant coumarin derivative in clinical use in North America is warfarin sodium.

Apixaban, dabigatran, rivaroxaban, edoxaban, and betrixaban are alternatives to warfarin for prophylaxis or treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE). Apixaban, edoxaban, rivaroxaban, and betrixaban inhibit factor Xa, whereas dabigatran is a direct thrombin inhibitor.

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Anticoagulants, Hematologic

Class Summary

Anticoagulant medications prevent further clot deposition. They allow the natural fibrinolytic mechanisms to lyse the existing clot.

Heparin

Heparin augments the activity of antithrombin III and prevents conversion of fibrinogen to fibrin. It does not actively lyse but is able to inhibit further thrombogenesis. The drug prevents the reaccumulation of clot after spontaneous fibrinolysis.

Warfarin (Coumadin, Jantoven)

Warfarin interferes with the hepatic synthesis of vitamin K–dependent coagulation factors. It is used for prophylaxis and treatment of venous thrombosis, PE, and thromboembolic disorders. Tailor the dose to maintain an international normalized ratio (INR) in the range of 2.0-3.0.

Enoxaparin (Lovenox)

Enoxaparin prevents DVT, which may lead to PE in patients undergoing surgery who are at risk for thromboembolic complications. The average duration of treatment is 7-14 days. Enoxaparin enhances the inhibition of factor Xa and thrombin by increasing antithrombin III activity. In addition, it preferentially increases the inhibition of factor Xa. Enoxaparin also has been approved for the treatment of DVT and PE.

Dalteparin (Fragmin)

Dalteparin is indicated for the prevention of DVT, which may lead to PE. It enhances the inhibition of factor Xa and thrombin by increasing antithrombin III activity. In addition, dalteparin preferentially increases the inhibition of factor Xa. The average duration of treatment is 7-14 days.

Rivaroxaban (Xarelto)

Rivaroxaban is an oral factor Xa inhibitor that inhibits platelet activation by selectively blocking the active site of factor Xa without requiring a cofactor (eg, antithrombin III) for activity. It is indicated for a variety of treatment and prophylaxis VTE indications, including risk reduction of stroke and systemic embolism in nonvalvular atrial fibrillation; treatment of DVT and PE; reduction in risk of recurrent DVT and/or PE; prophylaxis of DVT following hip or knee replacement surgery; prophylaxis of VTE in acutely ill medical patients at risk for thromboembolic complications owing to restricted mobility (and who are not at high risk of bleeding); and risk reduction of major CV events with CAD or PAD.

Dabigatran (Pradaxa)

Dabigatran is a direct thrombin inhibitor. Both free and clot-bound thrombin, and thrombin-induced platelet aggregation is inhibited. It is indicated for the treatment of DVT and PE in patients who have been treated with a parenteral anticoagulant for 5-10 days. It is also indicated to reduce the risk of DVT and PE recurrence in patients who have been previously treated.

Apixaban (Eliquis)

Apixaban is a factor Xa inhibitor indicated for treatment of DVT and PE. It is also indicated to reduce the risk of recurrence of DVT and PE in patients who have been previously treated.

Edoxaban (Savaysa)

Edoxaban is a factor Xa inhibitor indicated for treatment of DVT and PE in patients who have been initially treated with a parenteral anticoagulant for 5-10 days.

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Thrombolytic Agents

Class Summary

As stated by the American College of Chest Physicians, [35]  thrombolytic treatment is indicated for acute, massive PE with hemodynamic instability in patients who do not seem prone to bleeding. These agents dissolve recent clots promptly by activating a plasma proenzyme, plasminogen, to its active form, plasmin. Plasmin degrades fibrin to soluble peptides.

Thrombolytic therapy speeds pulmonary tissue reperfusion and rapidly reverses right heart failure. It improves pulmonary capillary blood flow and more rapidly improves hemodynamic parameters.

Reteplase; t-PA (Retavase)

Reteplase is used in the management of PE in hemodynamically unstable patients. Its safety and efficacy with concomitant administration of heparin or aspirin during first 24 hours after symptom onset have not been investigated.

Tenecteplase (TNKase)

Tenecteplase is a modified version of alteplase made by substituting three amino acids. It has a longer half-life than alteplase and thus can be given as a single bolus infused over 5 seconds (as opposed to the 90 minutes required for alteplase). It appears to cause less non–intracranial bleeding than alteplase but carries a comparable risk of intracranial bleeding and stroke.

Base the dose on the patient's weight. Initiate treatment as soon as possible after the onset of AMI symptoms. Because tenecteplase contains no antibacterial preservatives, it must be reconstituted immediately before use.

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Factor Xa Inhibitors

Class Summary

Blood coagulation cascade is dependent on the activation of factor X to factor Xa via the intrinsic and extrinsic pathways.

Apixaban (Eliquis)

Indicated to reduce risk of stroke and systemic embolism associated with nonvalvular atrial fibrillation. Also indicated for postoperative prophylaxis of DVT/PE and for treatment of DVT or PE.

Rivaroxaban (Xarelto)

Indicated for prophylaxis of DVT, which may lead to PE in patients undergoing knee or hip replacement surgery. Also indicated to reduce the risk of stroke in patients with nonvalvular atrial fibrillation. Additionally, it is indicated for treatment of DVT or PE.

Edoxaban (Savaysa)

Indicated to reduce risk of stroke and systemic embolism associated with nonvalvular atrial fibrillation (NVAF).

Betrixaban (Bevyxxa)

Indicated for prophylaxis of venous thromboembolism (VTE) in adults hospitalized for acute medical illness who are at risk for thromboembolic complications owing to moderate or severe restricted mobility and other risk factors that may cause VTE.

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Thrombin Inhibitors

Class Summary

Prevents thrombus development through direct, competitive inhibition of thrombin. Thrombin enables fibrinogen conversion to fibrin during the coagulation cascade.

Dabigatran (Pradaxa)

Inhibits free and clot-bound thrombin and thrombin-induced platelet aggregation. Indicated for prevention of stroke and systemic embolism associated with nonvalvular atrial fibrillation. Also indicated for prevention and treatment of DVT or PE.

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