Anti-thrombotic therapies

Direct oral anticoagulants (DOAC) on Formulary: 

Apixaban is currently the DOAC of choice in NHS Lothian for treatment of VTE in adults and for stroke prophylaxis in patients with non-valvular AF.  The safety and efficacy of apixaban for treatment of VTE in patients with active cancer has now been demonstrated in the CARAVAGGIO trial¹. Apixaban has also been shown to be effective as thromboprophylaxis in cancer patients starting SACT in the AVERT trial². 

Low molecular weight heparin (LMWH): 

Dalteparin (Fragmin®) is currently the brand of LMWH used in NHS Lothian. It is licensed and approved for use in: 

1. Prophylaxis of VTE 
2. Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) 

Warfarin

Warfarin is used rarely in patients with cancer or receiving SACT, but there are situations where it remains the most appropriate anticoagulant to use (e.g. patients with mechanical heart valves, valvular AF).  In these situations, anticoagulation should be discussed with the appropriate specialist managing their care, or haematology, if any changes to anticoagulation are being considered. 

Unfractionated heparin

Unfractionated heparin may be considered if immediate anticoagulation is required, if urgent reversal may be needed (e.g. known potential bleeding site) or if the creatinine clearance <30mL/min. Please consult LUHD Antithrombotic Guidelines (Adults) (only accessible when connected to intranet) and the associated protocols for further advice.