This supplement was written by William T. Elliott, MD, FACP, Chair, Formulary Committee, Kaiser Permanente, California Division; Assistant Clinical Professor of Medicine, University of California-San Francisco. In order to reveal any potential bias in this publication, we disclose that Dr. Elliott reports no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. For questions and comments, please e-mail: neill.kimball@ahcmedia.com.

When treating acute venous thromboembolism (VTE), the new oral anticoagulants are safe and effective alternatives to low-molecular-weight heparin (LMWH) followed by warfarin, according to a new study. The gold standard for treating acute VTE is LMWH followed by warfarin, but this regimen is often unwieldy for patients and requires frequent lab tests and follow-up. The new oral factor Xa inhibitors rivaroxaban (Xarelto) and apixaban (Eliquis) are both approved for initial treatment of VTE, but many physicians have safety concerns. The direct thrombin inhibitor dabigatran (Pradaxa) is also approved for VTE, but only after an initial course of LMWH. Using warfarin + LMWH as a comparator, eight different anticoagulation options were reviewed in a large meta-analysis. The regimens included LMWH plus dabigatran and the new agent edoxaban, as well as rivaroxaban and apixaban alone. Treatment outcomes were similar with all regimens except for unfractionated heparin with warfarin, which had the highest VTE recurrence rate. Bleeding rates were lowest with rivaroxaban and apixaban (hazard ratio, 0.55 and 0.31, respectively). The authors conclude that all regimens were of similar efficacy with the new Xa inhibitors rivaroxaban and apixaban associated with the lowest rate of bleeding (JAMA2014;312:1122-1135). This study may help change standard treatment for many emergency physicians who are looking to avoid cumbersome injection therapies for new diagnoses of VTE.

 

 

This supplement was written by William T. Elliott, MD, FACP, Chair, Formulary Committee, Kaiser Permanente, California Division; Assistant Clinical Professor of Medicine, University of California-San Francisco. In order to reveal any potential bias in this publication, we disclose that Dr. Elliott reports no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. For questions and comments, please e-mail: neill.kimball@ahcmedia.com.