Anticoagulants are the drugs of choice for treatment and prevention of deep venous thrombosis (DVT) and pulmonary embolism (PE), collectively referred to as venous thromboembolism (VTE). US guidelines for treatment of VTE were updated in 2020 and 2021.

View the Comparison Table: Some Parenteral Anticoagulants for VTE

Anticoagulants are the drugs of choice for treatment and prevention of deep venous thrombosis (DVT) and pulmonary embolism (PE), collectively referred to as venous thromboembolism (VTE). Updated US guidelines for treatment of VTE were published in 2016.

View the Comparison Table: Some Parenteral Anticoagulants for VTE

The FDA has approved betrixaban (Bevyxxa – Portola), a once-daily, oral, direct factor Xa inhibitor, for prophylaxis of venous thromboembolism (VTE) in adults hospitalized for an acute medical illness who have moderately or severely restricted mobility and other risk factors for VTE. Betrixaban is the first oral anticoagulant to be approved in the US for this indication.

The FDA has approved edoxaban (Savaysa – Daiichi Sankyo), a once-daily, oral, direct factor Xa inhibitor, for treatment of venous thromoboembolism (VTE) and for prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. It is the fourth new oral anticoagulant to be approved for VTE and nonvalvular atrial fibrillation.

The FDA has approved oritavancin (Orbactiv – The Medicines Company), a long-acting lipoglycopeptide antibiotic given as a single intravenous (IV) dose, for treatment of acute bacterial skin and skin structure infections caused by susceptible gram-positive bacteria in adults. It is the third lipoglycopeptide antibiotic to be marketed in the US; telavancin (Vibativ) and dalbavancin (Dalvance) were approved earlier.

Antiplatelet drugs are the drugs of choice for prevention and treatment of arterial thrombosis. Anticoagulants are the drugs of choice for prevention and treatment of venous thromboembolism and for prevention of cardioembolic events in patients with atrial fibrillation.

Anticoagulants are the drugs of choice for treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively referred to as venous thromboembolism (VTE).

Arterial thrombi are composed mainly of platelet aggregates held together by small amounts of fibrin. Antiplatelet drugs are the drugs of choice for prevention and treatment of arterial thrombosis, but anticoagulants are also effective, and their effects can add to those of antiplatelet drugs. Venous thrombi are composed mainly of fibrin and trapped red blood cells, with relatively few platelets. Anticoagulants are the agents of choice for prevention and treatment of venous thromboembolism and for prevention of cardioembolic events in patients with atrial fibrillation.

The treatment of atrial fibrillation includes ventricular rate control, anticoagulation, conversion to normal sinus rhythm and maintenance of sinus rhythm. The choice of therapies that can achieve these goals is discussed in the text that follows. Some drugs are recommended here for indications that have not been approved by the FDA.

The FDA has approved the use of recombinant human antithrombin (rhAT; ATryn - Lundbeck) in patients with inherited antithrombin (AT) deficiency to prevent thrombosis during or after surgery or childbirth. The protein is produced in the milk of transgenic goats carrying a copy of the human cDNA for AT. This is the first US drug approval for a protein produced by a transgenic animal. ATryn has been used in Europe since 2006.

Major orthopedic surgery creates a prothrombotic state by causing tissue injury during the operation and requiring relative immobilization during recovery. Without thromboprophylaxis, 40-60% of patients undergoing major knee or hip surgery develop venographically detectable deep vein thrombosis (DVT) and 1 in 300 undergoing total hip replacement will have a symptomatic pulmonary embolism (PE). Thromboprophylaxis reduces the incidence of venous thromboembolism (VTE), but it also can cause bleeding. New guidelines for prevention of VTE have recently been published.

Arterial and venous thrombosis are major causes of morbidity and mortality. Arterial thrombi consist of platelet aggregates held together by small amounts of fibrin. Antiplatelet drugs are the drugs of choice for prevention and treatment of arterial thrombosis, but anticoagulants are also effective, and their effects can add to those of antiplatelet drugs. Venous thrombi are composed mainly of fibrin and trapped red blood cells, with relatively few platelets. Anticoagulants are the agents of choice for prevention and treatment of venous thromboembolism and for prevention of cardioembolic events in patients with atrial fibrillation.

Percutaneous coronary intervention (PCI), such as balloon angioplasty or stent placement, predisposes to subsequent thrombosis. The current pharmacologic approach to prevention of this problem combines an anticoagulant with one or more antiplatelet drugs.

Bivalirudin is being promoted as an intravenous (IV) anticoagulant that can be used instead of heparin in patients with unstable angina undergoing coronary angioplasty.

Tenecteplase, a recombinant variant of human tissue plasminogen activator, is now available for thrombolysis in patients with acute myocardial infarction.

Clopidogrel bisulfate (Plavix - Bristol-Myers Squibb/Sanofi), a new thienopyridine antiplatelet agent similar to ticlopidine (Ticlid - Medical Letter, 34:65, 1992), has been approved by the US Food and Drug Administration (FDA) for secondary prevention of myocardial infarction, stroke and other vascular events.

Dalteparin (Fragmin - Pharmacia), the second low-molecular-weight heparin to be marketed in the USA, is now available for prevention of deep vein thrombosis in high-risk patients after abdominal surgery. Enoxaparin (Lovenox -Rh ne-Poulenc Rorer) was approved in 1993 for prevention of deep vein thrombosis after hip replacement (Medical Letter, 35:75, 1993) and later approved for use in knee replacement. Five other low-molecular-weight heparins and one heparinoid are under investigation in the USA (MJ Cziraky and SA Spinler, Clin Pharm, 12:892, 1993).

Enoxaparin (Lovenox - Rh ne-Poulenc Rorer), the first low-molecular-weight heparin to become commercially available in the USA, was recently approved by the US Food and Drug Administration for prevention of deep vein thrombosis following hip replacement. Five other products have been marketed in Europe.

Anistreplase (Eminase - SmithKline Beecham, Upjohn), a plasminogen activator also known as APSAC, was recently approved by the US Food and Drug Administration (FDA) for intravenous (IV) thrombolytic treatment of coronary thrombosis. Three other thrombolytic agents - intracoronary urokinase (Abbokinase) and intracoronary or intravenous streptokinase (Streptase; Kabikinase) and alteplase (TPA; Activase)- were previously approved for coronary thrombolysis (Medical Letter, 29:107, 1987).