TAM (Treatments and Medicines) NHS Highland
| Simplified Geneva | |
| Previous DVT/PE | 1 |
| HR 75 to 94 | 1 |
| HR ≥95 | 2 |
| Surgery or fracture within the last month | 1 |
| Haemoptysis | 1 |
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Pulmonary embolism (Guidelines)
Warning
What's new / Latest updates
25/11/24:
- Link to pulmonary embolism referral form added.
25/07/24:
- Rivaroxaban changed from first line to a second line option.
Audience
- Highland HSCP only
- Primary and Secondary Care
- Adults only
Acute pulmonary embolism (PE) is a common and sometimes fatal disease with a variable clinical presentation. This guideline details the investigation, diagnosis, management and follow up of patients with PE.
| sPESI: Simplified PESI | |
| Age >80 | 1 |
| Cancer | 1 |
| Chronic Heart Failure | 1 |
| HR ≥110 | 1 |
| Systolic BP <100 | 1 |
| Arterial saturation <90% | 1 |
If NO contraindications to thrombolysis, give alteplase:
- Weight ≥65kg: 100mg over 2 hours, administered as:
- 10mg IV bolus over 1 to 2 min, THEN
- 90mg IV infusion over 2 hours
- Weight <65kg: 1.5mg/kg over 2 hours, administered as:
- 10mg IV bolus over 1 to 2 min, THEN
- Remainder of dose as IV infusion over 2 hours
Injectable Medicines Guide access:
- IV monograph accessed via NHS Injectable Medicines Guide – Alteplase (Medusa) (NHS Highland intranet access required).
- Direct link: NHS Injectable Medicines Guide (password protected, available via Medicines Information).
- Also available via the Clinical Applications page of the NHS Highland intranet.
Absolute contra-indications to thrombolysis include:
- Intracranial neoplasm
- Recent (<2 months) intracranial or spinal surgery or trauma
- History of a haemorrhagic stroke
- Active bleeding or bleeding diathesis (eg, severe thrombocytopenia)
- Treatment with anticoagulant
- Or non-haemorrhagic stroke, within the previous three months.
Relative contra-indications to thrombolysis include:
- Severe uncontrolled hypertension (systolic blood pressure >200 mmHg or diastolic blood pressure >110 mmHg)
- Non-haemorrhagic stroke more than three months prior
- Surgery within the previous 10 days
- Pregnancy
- Haemorrhagic or ischaemic stroke in preceding 6 months
Complete drug information: Actilyse 10 mg powder and solvent for solution for injection and infusion - Summary of Product Characteristics
First-line option:
Apixaban
- 10mg twice daily for 7 days, THEN
- 5mg twice daily for at least 3 months (See: Treatment duration and follow-up)
Detailed drug information: Apixaban 5mg Film-Coated Tablets - Summary of Product Characteristics (SmPC)
Second-line options:
Rivaroxaban
- 15mg twice daily for 21 days, THEN
- 20mg once daily for at least 3 month (See: Treatment duration and follow-up)
Detailed drug information: Xarelto 15mg film-coated tablets - Summary of Product Characteristics (SmPC)
Dabigatran and edoxaban.
- Note: requirement for 5 days of treatment dose low molecular weight heparin before initiating edoxaban for PE.
- See SPC’s for detailed prescribing information.
Notes:
- All patients commenced DOAC should have medications reviewed:
- Antiplatelets: consider stopping, unless clear indication to continue antiplatelet in combination with DOAC. Consider discussing with Cardiology, where appropriate.
- NSAID’s: bleeding risk, avoid where possible.
- Check detailed drug interaction information: Medicines Complete — Stockley's Interactions Checker
- All patients initiated on DOAC should receive verbal and written information prior to discharge, see: DOAC Counselling Tool (NHS Highland intranet access required)
DOAC contra-indicated or unsuitable at present:
Low Molecular Weight Heparin (LMWH):
Enoxaparin
- CrCl ≥30mL/min AND low risk of recurrence:
1.5mg/kg once daily by subcutaneous injection - CrCl ≥30mL/min AND additional risk factors (eg, obesity, cancer, recurrent VTE, symptomatic PE):
1mg/kg twice daily (12 hourly) by subcutaneous injection - CrCl <30mL/min:
1mg/kg once daily by subcutaneous injection
Maximum initiation dose of enoxaparin is 120mg. In patients who weigh >120kg, use 120mg twice daily (provided CrCl >30mL/min), and seek specialist haematology advice +/- monitoring of Xa levels.
Treatment Duration
Provoked PEs (transient/reversible risk factor)
- Discontinue anticoagulation after 3 months (6 months in active cancer)
Unprovoked or recurrent PEs:
- Continue anticoagulation for at least 6 months and refer to PE clinic
Follow-up
Patients who should be referred to the PE service for follow-up include:
- All patients under the age of 50 with PE
- All unprovoked PE
- Recurrent PE
- All intermediate-high and high risk PE, as determined by the Risk Stratification above
Treatment duration >6 months may be appropriate for high risk / recurrent PE patients. Final decision will be made at PE clinic.
Please contact obstetrics/gynaecology
Pulmonary Embolism service referral form (NHS Highland intranet access required).