Pulmonary embolism (Guidelines)

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