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Evidence summaries

Oral Direct Thrombin Inhibitors or Oral Factor Xa Inhibitors for the Treatment of Pulmonary Embolism

There appear to be no differences in efficacy between direct oral anticoagulants (DOACs) and conventional anticoagulation for the long-term treatment of pulmonary embolism. Level of evidence: "B"

The quality of evidence is downgraded by imprecise results (few outcome events).

Summary

A Cochrane review [Abstract] 1 included 10 studies with a total of 13 073 subjects with pulmonary embolism (PE). Two studies tested oral direct thrombin inhibitors (DTIs) (dabigatran) and 8 studies tested oral factor Xa inhibitors (3 rivaroxaban, 3 apixaban, and 2 edoxaban).

There was no difference in the effectiveness of oral DTIs and conventional anticoagulation in preventing recurrent PE, recurrent venous thromboembolism, deep vein thrombosis (DVT) and major bleeding (table T1).

Oral direct thrombin inhibitors (DTIs) versus conventional anticoagulation for the treatment of pulmonary embolism

OutcomeRelative effect (95% CI)Assumed risk - conventional anticoagulationCorresponding risk - oral DTI (95% CI)Participants (studies)
Recurrent pulmonary embolismOR 1.02(0.50 to 2.04)20 per 100020 per 1000(10 to 40)1 602 (1 study)
Recurrent venous thromboembolismOR 0.93(0.52 to 1.66)31 per 100029 per 1000(16 to 50)1 602 (1 study)
Deep vein thrombosisOR 0.79(0.29 to 2.13)11 per 10009 per 1000(3 to 23)1 602 (1 study)
Major bleedingOR 0.50(0.15 to 1.68)10 per 10005 per 1000(2 to 17)1 527 (1 study)

For oral factor Xa inhibitors, there was no clear difference in the rate of recurrent PE, venous thromboembolism, DVT, all-cause mortality or major bleeding (table T2).

Oral factor Xa inhibitors versus conventional anticoagulation for the treatment of pulmonary embolism

OutcomeRelative effect (95% CI)Assumed risk - conventional anticoagulationCorresponding risk - oral factor Xa (95% CI)Participants (studies)
Recurrent pulmonary embolismOR 0.92(0.66 to 1.29)18 per 100016 per 1000(12 to 23)8 186(3 studies)
Recurrent venous thromboembolismOR 0.83(0.66 to 1.03)32 per 100026 per 1000(21 to 33)11 416(8 studies)
Deep vein thrombosisOR 0.77(0.48 to 1.25)10 per 10007 per 1000(5 to 12)8 151(2 studies)
All-cause mortalityOR 1.16(0.79 to 1.70)21 per 100024 per 1000(16 to 35)4 817 (1 study)
Major bleedingOR 0.71(0.36 to 1.41)¹23 per 100016 per 1000(8 to 32)11 447 (8 studies)
¹statistical heterogeneity, I2 = 79%
Clinical comments

Note

Date of latest search:

    References

    • Li M, Li J, Wang X, et al. Oral direct thrombin inhibitors or oral factor Xa inhibitors versus conventional anticoagulants for the treatment of pulmonary embolism. Cochrane Database Syst Rev 2023;4(4):CD010957 [PubMed]

    Primary/Secondary Keywords