Can you use a NOAC to treat DVT/PE?

Let’s say you have the following patient: 80 year old male with COPD and diabetes who comes into the ED with dizziness and SOB. The emergency department gets a CTA, which for once, shows subsegmental PEs in his right and left lungs. He is started on a heparin drip and admitted to your team. What happens next?

The first decision you need to make is whether to start him on warfarin or a novel anticoagulant (NOAC). This category of medications includes drugs like rivaroxaban, apixaban, and dabigatran. We could have a whole discussion about when warfarin might be more preferable, or a NOAC. Parts of that discussion can be found here and here (specific to non-valvular afib).

You decide to start the patient on a NOAC. Fine. Now the question is, which one do you choose? Enter the EINSTEIN-PE trial, summarized in this 2-Minute Medicine article. This trial examined how rivaroxaban, or Xarelto, compared to lovenox + warfarin. Rivaroxaban was non-inferior and had fewer bleeding events. This supports the use of rivaroxaban for treating PE. Unfortunately, there is no such data for apixaban or dabigatran. Therefore, rivaroxaban is the NOAC of choice when treating PE.

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