title: Treatment of pulmonary embolism.
abstract: The treatment of pulmonary embolism is going to be deeply modified by the development of Direct Oral Anticoagulants (DOACs). There are currently three anti-Xa factors (rivaroxaban, apixaban, edoxaban) and one anti-IIa factor (dabigatran) labeled by the FDA and the EMA. All these drugs are direct anticoagulant, orally effective, without the need for adaptation to hemostasis test. As kidney excretion is involved for all of them, they are contra-indicated in patients with severe renal failure (creatinine clearance < 30 mL/min according to Cockcroft & Gault formula). All the anti-Xa factor drugs are metabolized by liver cytochromes and then contra-indicated in case of liver insufficiency. Of note, the four DOACS have been evaluated in non-inferiority trials, including one open-label trial (the EINSTEIN program with the rivaroxaban). Moreover, two of them (rivaroxaban and apixaban) were evaluated in a single drug approach (provided initial increased doses: 15 mg bid during 21 days for rivaroxaban and 10 mg bid during 7 days for apixaban) whereas the two others (edoxaban and dabigatran) were evaluated after at least 5 days of parenteral heparin. They were found to be non-inferior to the conventional treatment, but also seem to be associated with a decreased risk of major bleeding, in a quite young and without significant comorbidities population. The risk/benefit ratio of DOACs in specific subgroups deserves prospective validations.
authors.affiliation: CHU de Saint-Étienne, hôpital Nord, CIC-EC Inserm, CIC1408, 42055 Saint-Étienne cedex, France; Université Jean-Monnet, EA3065, 42023 Saint-Étienne, France; CHU de Saint-Étienne, hôpital Nord, service de médecine vasculaire et thérapeutique, 42055 Saint-Étienne, France; CHU de Saint-Étienne, hôpital Nord, GIRC-thrombose, INNOVTE network, 42055 Saint-Étienne, France. Electronic address: herve.decousus@chu-st-etienne.fr.
authors.forename: Hervé
authors.initials: H
authors.lastname: Décousus
authors.affiliation: CHU de Saint-Étienne, hôpital Nord, CIC-EC Inserm, CIC1408, 42055 Saint-Étienne cedex, France; Université Jean-Monnet, EA3065, 42023 Saint-Étienne, France; CHU de Saint-Étienne, hôpital Nord, service de médecine vasculaire et thérapeutique, 42055 Saint-Étienne, France; CHU de Saint-Étienne, hôpital Nord, GIRC-thrombose, INNOVTE network, 42055 Saint-Étienne, France.
authors.forename: Patrick
authors.initials: P
authors.lastname: Mismetti
authors.affiliation: CHU de Saint-Étienne, hôpital Nord, GIRC-thrombose, INNOVTE network, 42055 Saint-Étienne, France; Centre hospitalo-universitaire de Brest, département de médecine interne et pneumologie, 29200 Brest, France; Université de Bretagne occidentale, CIC Inserm 1412, EA 3878, 29200 Brest, France.
authors.forename: Francis
authors.initials: F
authors.lastname: Couturaud
authors.affiliation: University of Insubria, department of clinical and experimental medicine, Varese, Italy.
authors.forename: Walter
authors.initials: W
authors.lastname: Ageno
authors.affiliation: Darmstadt hospital, department of vascular medicine, Darmstadt, Germany; University of Mainz, center of thrombosis and haemostasis, Mainz, Germany.
authors.forename: Rupert
authors.initials: R
authors.lastname: Bauersachs
mesh_terms: D000991:Antithrombins / Q000627:therapeutic use*; D002986:Clinical Trials as Topic; D000069604:Dabigatran / Q000627:therapeutic use; D065427:Factor Xa Inhibitors / Q000627:therapeutic use; D006801:Humans; D011655:Pulmonary Embolism / Q000188:drug therapy*; D011720:Pyrazoles / Q000627:therapeutic use; D011725:Pyridines / Q000627:therapeutic use; D011728:Pyridones / Q000627:therapeutic use; D018570:Risk Assessment; D000069552:Rivaroxaban / Q000627:therapeutic use; D013844:Thiazoles / Q000627:therapeutic use; D054556:Venous Thromboembolism / Q000188:drug therapy
chemical_list: D000991:Antithrombins; D065427:Factor Xa Inhibitors; D011720:Pyrazoles; D011725:Pyridines; D011728:Pyridones; D013844:Thiazoles; C522181:apixaban; D000069552:Rivaroxaban; D000069604:Dabigatran; C552171:edoxaban