Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Novel Anticoagulants for Pulmonary Embolism Care in Australia

  Pulmonary embolism (PE) occurs when a blood clot, usually originating in a deep vein in the leg, travels to the pulmonary arteries. It can cause sudden breathlessness, pleuritic chest pain, tachycardia, syncope or unexplained hypoxaemia. Rapid assessment is essential because the clinical spectrum ranges from a small, stable clot to life-threatening right ventricular failure.

  Novel oral anticoagulants, more accurately called direct oral anticoagulants (DOACs), have changed the management of venous thromboembolism. Apixaban and rivaroxaban can usually be started without an initial injectable anticoagulant, while dabigatran and edoxaban require several days of heparin-based treatment first. Selection depends on haemodynamic status, kidney function, bleeding risk, pregnancy status, drug interactions and the practicalities of follow-up.

  Anticoagulant	Initial treatment approach	Key practical considerations
  Apixaban	Oral loading regimen, then maintenance dosing	Fewer food restrictions; dose adjustment may be needed in selected patients
  Rivaroxaban	Higher oral dose initially, then maintenance dosing	Should be taken with food at relevant doses
  Dabigatran	At least five days of parenteral anticoagulation first	Renal clearance is important; capsules must remain in original packaging
  Edoxaban	At least five days of parenteral anticoagulation first	Dose depends on kidney function, body weight and selected interactions
  Unfractionated heparin	Intravenous treatment, often in hospital	Useful when rapid reversal, procedures or severe renal impairment are concerns

  Choosing An Oral Anticoagulant

  For a haemodynamically stable adult with confirmed PE, apixaban or rivaroxaban often offers a straightforward oral pathway. These agents have a rapid onset and avoid routine international normalised ratio monitoring. That can be valuable for people living outside Sydney, Melbourne, Brisbane or other major centres, where repeated pathology appointments may be inconvenient.

  Dabigatran and edoxaban remain effective options, but their requirement for an initial course of low-molecular-weight heparin or intravenous heparin can complicate discharge planning. Warfarin may still be appropriate when cost, severe kidney disease, antiphospholipid syndrome or a need for measurable anticoagulant intensity influences the decision.

  Assessing Severity And Safety

  DOAC therapy is generally intended for stable PE, not for patients in shock or with severe haemodynamic compromise. High-risk PE may require intensive care, echocardiography, systemic thrombolysis, catheter-directed treatment or surgical embolectomy. Anticoagulation should be coordinated with a multidisciplinary team when right ventricular strain or cardiac instability is present.

  Before prescribing, clinicians should review full blood count, renal and liver function, current medicines, recent surgery and previous bleeding. Non-steroidal anti-inflammatory drugs, antiplatelet medicines and some anticonvulsants can increase bleeding or alter drug exposure. Pregnancy and breastfeeding require a different approach, commonly involving specialist advice and heparin-based treatment.

  Duration And Follow-Up

  The usual treatment period is at least three months, although the appropriate duration depends on whether the PE was provoked by surgery, hospitalisation, immobility, oestrogen exposure or another temporary factor. Unprovoked PE, recurrent venous thromboembolism, active cancer and persistent risk factors may justify extended anticoagulation after an individual bleeding-risk assessment.

  Follow-up should assess breathlessness, chest pain, exercise tolerance, adherence and signs of bleeding. Persistent dyspnoea after treatment warrants evaluation for chronic thromboembolic pulmonary hypertension or another cardiopulmonary condition. A medication review is particularly useful when patients take over-the-counter aspirin or ibuprofen for common Australian outdoor, sporting or musculoskeletal injuries.

  Australian Access And Regulation

  In Australia, DOAC prescribing sits within the Therapeutic Goods Administration (TGA) regulatory framework, while Pharmaceutical Benefits Scheme (PBS) listings and authority requirements can affect affordability and access. Hospital formularies, private prescriptions and current PBS criteria may differ, so clinicians should verify the latest listing rather than relying on older protocols.

  The local market includes branded and, where available, generic formulations, with supply and pricing changing over time. Patients who travel long distances in Western Australia, Queensland or the Northern Territory may need a sufficient supply and a clear plan for pathology, repeat prescriptions and urgent care. Telehealth can support follow-up, but it does not replace assessment of suspected recurrent PE or significant bleeding.

  Practical Recommendations For PE Care

  • Confirm the diagnosis and clinical severity before selecting an oral anticoagulant.
  • Check renal and hepatic function, weight, pregnancy status and interacting medicines.
  • Prefer an approved DOAC regimen for stable patients when there is no major contraindication.
  • Explain missed-dose instructions, bleeding symptoms and the danger of stopping treatment abruptly.
  • Review PBS eligibility, dispensing access and medicine storage before discharge.
  • Arrange follow-up for adherence, recurrent symptoms, bleeding and the planned treatment duration.

  Safe prescribing depends on matching the medicine to the patient rather than treating all PE presentations alike. A stable person in Adelaide may be well suited to an oral regimen, while a patient with shock, severe renal impairment or an urgent procedure may need intravenous unfractionated heparin in hospital. The practical takeaway is to confirm PE severity, kidney function, bleeding risk and local access before selecting and continuing a DOAC.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)