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Hematology · Dosing

VTE treatment

DVT or PE confirmed: which anticoagulants this patient can take, the US-label dose for each phase, the renal cutoffs, and what to avoid and why. Cancer, pregnancy, triple-positive APS, kidney function, weight and interacting drugs all feed one answer.

FDA-label doses by phaseCancer · pregnancy · APSRenal cutoffs + interactionsReviewed Oct 2026

1Diagnosis

Objectively confirmed VTE in an adult. PE: set severity first in the PE pathway. Prophylaxis is a different question: see thromboprophylaxis.

2Weight and kidney function

3Situations that change the drug

Triple-positive: lupus anticoagulant, anticardiolipin and anti-β2-glycoprotein I all positive.

4Contraindication screen

5Interacting drugs named in the US labels

6Bleeding risk Hestia definitions

7What provoked it optional — duration only

Major transient: e.g., surgery with general anesthesia over 30 min, or hospital bed rest, within 3 months. Persistent: e.g., active cancer or inflammatory disease (CHEST 2021 examples).

How it works

Dose rules used (US labels)
AgentDVT or PE treatmentKidney
Apixaban10 mg twice daily for 7 days, then 5 mg twice daily. After at least 6 months: 2.5 mg twice daily.No adjustment, including dialysis (PK-based; CrCl under 15 not studied)
Rivaroxaban15 mg twice daily with food for 21 days, then 20 mg daily with food. After at least 6 months: 10 mg daily.CrCl 15 or more; 15 to 29 limited data; under 15 avoid. Actual weight for CrCl.
DabigatranParenteral 5 to 10 days, then 150 mg twice daily.CrCl over 30 only; 30 or less or dialysis: no label dose
EdoxabanParenteral 5 to 10 days, then 60 mg daily. 30 mg if CrCl 15 to 50, weight 60 kg or less, or a listed P-gp inhibitor.Under 15: not recommended
Enoxaparin1 mg/kg every 12 h, or 1.5 mg/kg daily (inpatients). Actual weight; no label maximum. Exception: mechanical valve in pregnancy — dose-adjusted at least twice daily to an anti-Xa level of 0.8–1.2 U/mL (2020 ACC/AHA).CrCl under 30: 1 mg/kg once daily
UFH80 units/kg bolus, 18 units/kg/h (Raschke), or label 5,000 units then 20,000–40,000 units/24 h; adjust to aPTT 1.5–2× normal.No label adjustment

CrCl is shown rounded down to a whole number and classified on that number, so every cutoff errs toward the safer side.

Interactions the labels name

Apixaban: combined P-gp and strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir): cut the 10 mg and 5 mg doses by 50%; avoid with 2.5 mg. Clarithromycin: no adjustment. Avoid combined inducers (rifampin, carbamazepine, phenytoin, St John’s wort).

Rivaroxaban: avoid combined P-gp and strong CYP3A inhibitors (ketoconazole, ritonavir) and inducers (carbamazepine, phenytoin, rifampin, St John’s wort). Erythromycin with CrCl 15 to under 80: not unless benefit justifies risk. Clarithromycin: no precautions.

Dabigatran: avoid P-gp inducers (rifampin). For DVT and PE, avoid any P-gp inhibitor when CrCl is under 50 (§7.2). The label names dronedarone, ketoconazole, verapamil, amiodarone, quinidine, clarithromycin and ticagrelor; the tool also treats itraconazole and ritonavir (apixaban label), erythromycin (rivaroxaban label), azithromycin (edoxaban label) and cyclosporine (FDA interaction table) as P-gp inhibitors.

Edoxaban: Hokusai VTE used 30 mg with verapamil, quinidine, or short courses of azithromycin, clarithromycin, erythromycin, oral itraconazole or ketoconazole. Other P-gp inhibitors were not permitted; ritonavir and cyclosporine were excluded. Avoid rifampin.

Where a label is silent on a drug you ticked, the tool says so instead of guessing. ASH 2018 suggests a VKA or LMWH over a DOAC when a P-gp or strong CYP inhibitor or inducer is needed.

Special populations

Pregnancy: LMWH over UFH (ASH 2018, strong). Oral anticoagulants are avoided for fetal risk. Once- or twice-daily LMWH; no routine anti-Xa monitoring. Exception — mechanical valve: 2020 ACC/AHA uses dose-adjusted LMWH at least twice daily with anti-Xa monitoring (0.8–1.2 U/mL 4–6 h after the dose), or warfarin when 5 mg/day or less is needed; the regimen is set with cardiology and maternal-fetal medicine.

Cancer: CHEST 2021 recommends apixaban, edoxaban or rivaroxaban over LMWH. With luminal GI cancer, edoxaban and rivaroxaban had more GI major bleeding than LMWH; apixaban or LMWH may be preferred.

APS: triple-positive — all four DOAC labels: not recommended. Any confirmed APS — CHEST 2021 #17 suggests adjusted-dose VKA, target INR 2.5, over a DOAC; EULAR 2019 #4A: VKA, INR 2 to 3.

Unstable PE: the apixaban (§5.5) and rivaroxaban (§5.9) labels: not an alternative to UFH in PE with hemodynamic instability or possible thrombolysis or embolectomy.

Large doses: the tool flags an enoxaparin single dose over 150 mg or weight over 150 kg. That threshold is the tool’s, not a guideline’s; it prompts a pharmacist check, not a cap.

Obesity: enoxaparin by actual weight, not a capped dose, without routine anti-Xa monitoring (ASH 2018). NICE: consider monitoring drug levels under 50 kg or over 120 kg.

Sources

  1. ELIQUIS (apixaban) US prescribing information, E.R. Squibb & Sons / Bristol-Myers Squibb, revised 04/2025 (DailyMed setid e9481622-7cc6-418a-acb6-c5450daae9b0). Sections 2.1, 2.6, 4, 5.4–5.6, 7.1–7.2, 8.1–8.2, 8.6–8.7.
  2. XARELTO (rivaroxaban) US prescribing information, Janssen, revised 09/2026 (DailyMed setid 10db92f9-2300-4a80-836b-673e1ae91610). Table 1, sections 4, 5.4, 5.6–5.10, 7.2–7.3, 8.6–8.7.
  3. PRADAXA (dabigatran etexilate) capsules US prescribing information, Boehringer Ingelheim, revised 06/2025 (DailyMed setid ba74e3cd-b06f-4145-b284-5fd6b84ff3c9). Sections 2.2, 4, 5.4–5.6, 7.
  4. SAVAYSA (edoxaban) US prescribing information, Daiichi Sankyo, revised 07/2025 (DailyMed setid e77d3400-56ad-11e3-949a-0800200c9a66). Sections 2.2, 4, 5.5–5.6, 7.2–7.3, 8.6–8.8, 14.2 (Hokusai VTE).
  5. LOVENOX (enoxaparin) US prescribing information, Sanofi, revised 05/2026 (DailyMed setid 5017a927-2a24-4f27-89f9-27c805bf7d59). Sections 2.2, 2.3 (Table 1), 4, 8.6–8.9.
  6. Heparin Sodium Injection US prescribing information, Pfizer, revised 10/2025 (DailyMed setid 56dc3074-f1c5-45a3-b923-f1d14858e06d). Sections 2.2–2.3, 4.
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  16. National Institute for Health and Care Excellence. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (NG158), 2020, updated 2023. Recommendations 1.3.8–1.3.20 (1.3.12: continuous UFH for haemodynamic instability), 1.7.
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Educational reference only — not a substitute for clinical judgment, institutional protocols, or specialist advice. Calculations run in your browser; nothing you enter is sent or stored.