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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Treatment of pulmonary embolism

Respiratory · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Escalate

Any confirmed or suspected PE with cardiac arrest, shock, persistent hypotension, worsening perfusion or rapidly deteriorating oxygenation leaves the routine anticoagulation pathway and requires immediate high-risk PE/reperfusion assessment.

Synopsis

Treat confirmed haemodynamically stable PE with the right anticoagulant, dose, duration and follow-up plan while recognising patients who need admission, a different drug strategy or urgent escalation.

  • For confirmed proximal DVT or PE, NICE recommends therapeutic anticoagulation for at least 3 months.
  • For most haemodynamically stable adults, offer apixaban or rivaroxaban if suitable; each has a mandatory higher-dose initial phase.
  • Apixaban: 10 mg twice daily for 7 days, then 5 mg twice daily. Rivaroxaban: 15 mg twice daily for 21 days, then 20 mg once daily with food.
  • If apixaban and rivaroxaban are unsuitable, options include LMWH for at least 5 days followed by dabigatran or edoxaban, or LMWH/UFH overlapped with a vitamin K antagonist until the INR is therapeutic.
  • Before selection, check active bleeding, FBC/platelets, renal and liver function, pregnancy possibility, body weight, cancer site, antiphospholipid syndrome, interacting medicines and ability to adhere.
  • Use a validated low-risk tool plus clinical judgement when considering outpatient treatment; social support, bleeding risk, comorbidity, oxygen need and reliable follow-up also matter.
  • At 3 months review whether the PE was provoked, whether the provoking factor has resolved, recurrence risk, bleeding risk and patient preference.
  • Consider stopping after 3 months for a provoked PE with a resolved provoking factor and an uncomplicated course; consider continuing beyond 3 months after unprovoked PE when recurrence risk outweighs bleeding risk.
  • Active cancer usually requires 3–6 months of treatment followed by reassessment; tumour site, drug interactions and bleeding risk determine whether a DOAC or LMWH is preferred.
  • Triple-positive antiphospholipid syndrome is a vitamin K antagonist pathway, not routine DOAC treatment.

    • Key red flags

    Bleeding or anticoagulant contraindication

    Active major bleeding, recent high-risk surgery, severe thrombocytopenia, intracranial pathology or another major haemorrhage risk requires senior haematology/specialty discussion and sometimes a temporary IVC filter.

    Deterioration on treatment

    New hypotension, syncope, rising lactate, increasing oxygen need or chest pain demands immediate reassessment for high-risk PE, bleeding, recurrent embolism or an alternative diagnosis.

    Investigation priorities

    01
    FBC and platelet countFirst step

    Identify anaemia, thrombocytopenia and a baseline for bleeding/HIT surveillance.

    Management branches

    First lineStable confirmed PE in most adults

    Confirmed PE, haemodynamically stable, no major contraindication and apixaban/rivaroxaban suitable.

    1. Document baseline FBC, renal/liver function, coagulation, weight, bleeding risk, interactions and pregnancy status where relevant.
    2. Start either apixaban 10 mg twice daily for 7 days then 5 mg twice daily, or rivaroxaban 15 mg twice daily for 21 days then 20 mg once daily with food; prescribe the transition date explicitly.
    3. Decide admission versus outpatient care using a validated risk tool plus clinical/social criteria and provide anticoagulant counselling, written bleeding advice and contact details.
    4. Arrange a three-month review before the prescription expires; do not leave duration implicit.

    Key medicines

    Apixaban10 mg orally twice daily for 7 days, then 5 mg twice daily; if extended prevention is chosen after 6 months, the licensed prevention dose is 2.5 mg twice daily.Active bleeding, significant hepatic coagulopathy, interacting strong CYP3A4/P-gp drugs and pregnancy. Check current SmPC for renal and peri-procedural advice; the AF dose-reduction rule must not be copied into acute VTE treatment.
    Rivaroxaban15 mg orally twice daily with food for 21 days, then 20 mg once daily with food; after at least 6 months, 10 mg once daily is licensed for extended prevention, with 20 mg considered when recurrence risk is high.Active bleeding, significant liver disease/coagulopathy, renal impairment and interacting drugs. The 15 mg and 20 mg doses must be taken with food; document the day-22 switch.
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    Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
    Sources

    Sources and review status

    National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

    • NICE NG158: Venous thromboembolic diseases—recommendationsFirst-line selection, at least 3 months' treatment, special populations and review.
    • Eliquis 5 mg SmPCCurrent licensed apixaban VTE dosing and cautions.
    • Xarelto 20 mg SmPCCurrent licensed rivaroxaban VTE dosing and extended prevention.
    • Clexane SmPCLicensed enoxaparin treatment dosing and safety information.
    • Pradaxa 150 mg SmPCDabigatran VTE regimen after parenteral anticoagulation.

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom