Table 5.

Suggestions for choice of anticoagulant for acute VTE treatment

Characteristic	Drug choice	Rationale
Extensive DVT or massive PE	Heparin	Such patients often require advanced therapy and were excluded from trials with the NOACs
High initial risk of bleeding	Heparin	Enables dose titration; rapid offset and availability of protamine as an antidote simplify management should bleeding occur
Active cancer	LMWH	No trials comparing NOACs with LMWH
Pregnancy	LMWH	Warfarin and NOACs cross the placenta
Liver dysfunction with increased prothrombin time/INR at baseline	Warfarin	Such patients were excluded from the trials because NOACs undergo hepatic metabolism
Unable to afford NOACs	LMWH followed by warfarin	NOACs cost less than LMWH but are more expensive than warfarin
Limited access to anticoagulation clinic because of impaired mobility or geographical inaccessibility	NOAC	Given in fixed doses without monitoring
All-oral therapy	Rivaroxaban or apixaban	Only NOACs to be evaluated in all-oral regimens
Creatinine clearance <30 mL/min	Warfarin	Such patients were excluded from trials with NOACs
Creatinine clearance 30-50 mL/min	Rivaroxaban, apixaban, or edoxaban	Less affected by renal impairment than dabigatran; if edoxaban is chosen, the 30-mg OD dose should be used
Dyspepsia or upper gastrointestinal symptoms	Rivaroxaban, apixaban, or edoxaban	Dyspepsia in as much as 10% given dabigatran
Recent gastrointestinal bleed	Apixaban	More gastrointestinal bleeding with dabigatran, rivaroxaban, and edoxaban than with warfarin
Recent acute coronary syndrome	Rivaroxaban, apixaban or edoxaban	Small myocardial infarction signal with dabigatran
Poor compliance with long-term twice-daily dosing	Rivaroxaban or edoxaban	OD regimens for long-term use

OD, once daily; LMWH, low-molecular-weight heparin.