Treatment

DOACs have made it easier for patients to take anticoagulants and achieve reliable anticoagulation both as inpatients and outpatients. Rivaroxaban and apixaban are commonly used DOACs for PE and demonstrate similar safety and efficacy in real-world settings. Despite the ease of administration, however, insurance companies may require preauthorization or have a preferred DOAC, which can be a headache to sort out in the emergency department. Many clinicians and emergency departments take advantage of the coupons for free or significantly discounted medications from the pharmaceutical company to initiate treatment, then inform the patient that their primary care physician may switch the anticoagulant in the future (for example, www.eliquis.com/eliquis/hcp/resources and www.janssencarepath.com/hcp/xarelto/savings-program-overview ).

In the age of DOACs, the benefits of hospitalization for a substantial fraction of patients with low-risk PE are minimal or nonexistent. Interestingly, despite professional society guidance and a decade of safety data, outpatient management of PE in the United States varies widely, with signals that the practice is largely institution- rather than patient-dependent.^5,14 Institutions and clinicians should work to implement protocols to identify and treat appropriate patients with low-risk PE in the outpatient setting.

Dr. Westafer (@Lwestafer) is an attending physician and research fellow at Baystate Medical Center, clinical instructor at the University of Massachusetts Medical School in Worcester, and co-host of FOAMcast.

References

1. Jiménez D, de Miguel-Díez J, Guijarro R, et al. Trends in the management and outcomes of acute pulmonary embolism: analysis from the RIETE registry. J Am Coll Cardiol. 2016;67(2):162-170.
2. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016; 149(2):315-352.
3. Wolf SJ, Hahn SA, Nentwich LM, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected acute venous thromboembolic disease. Ann Emerg Med. 2018;71(5):e59-e109.
4. Aujesky D, Roy PM, Verschuren F, et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet. 2011;378(9785):41-48.
5. Westafer LM, Shieh M-S, Pekow PS, et al. Outpatient management of patients following diagnosis of acute pulmonary embolism. Acad Emerg Med. 2021;28(3):336-345.
6. den Exter PL, Zondag W, Klok FA, et al. Efficacy and safety of outpatient treatment based on the Hestia clinical decision rule with or without N-terminal pro-brain natriuretic peptide testing in patients with acute pulmonary embolism. A randomized clinical trial. Am J Respir Crit Care Med. 2016;194(8):998-1006.
7. Piran S, Le Gal G, Wells PS, et al. Outpatient treatment of symptomatic pulmonary embolism: a systematic review and meta-analysis. Thromb Res. 2013;132(5):515-519.
8. Maughan BC, Frueh L, McDonagh MS, et al. Outpatient treatment of low‐risk pulmonary embolism in the era of direct oral anticoagulants: a systematic review. Acad Emerg Med. 2021;28(2):226-239.
9. Elias A, Mallett S, Daoud-Elias M, et al. Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis. BMJ Open. 2016;6(4):e010324.
10. Quezada CA, Bikdeli B, Villén T, et al. Accuracy and interobserver reliability of the simplified pulmonary embolism severity index versus the Hestia criteria for patients with pulmonary embolism. Acad Emerg Med. 2019;26(4):394-401.
11. Zongdag W, Mos ICM, Creemers-Schild D, et al. Outpatient treatment in patients with acute pulmonary embolism: the Hestia study. J Thromb Haemost. 2011;9(8):1500-1507.
12. Peacock WF, Singer AJ. Reducing the hospital burden associated with the treatment of pulmonary embolism. J Thromb Haemost. 2019;17(5):720-736.
13. Aryal MR, Gosain R, Donato A, et al. Systematic review and meta-analysis of the efficacy and safety of apixaban compared to rivaroxaban in acute VTE in the real world. Blood Adv. 2019;3(15):2381-2387.
14. Vinson DR, Mark DG, Chettipally UK, et al. Increasing safe outpatient management of emergency department patients with pulmonary embolism: a controlled pragmatic trial. Ann Intern Med. 2018;169(12):855-865.