Apixaban After Alteplase for Pulmonary Embolism

Background: Pulmonary embolism guidelines recommend starting parenteral anticoagulation after completion of thrombolytic therapy for patients who receive thrombolytics; however, there is no guidance on dosing factor Xa inhibitors in this population upon transition to oral anticoagulation. Prior to the Food and Drug Administration approval of direct oral anticoagulants, warfarin was the standard of care, which does not have a standard dose; rather, it has a standard goal international normal range. Objective: The study’s aim was to assess the safety and efficacy of apixaban at standard thromboembolic dosing versus alternative dosing after alteplase in patients who received systemic thrombolytic therapy for pulmonary embolism. Methods: This study was approved by the institutional review board and was a retrospective, non-interventional cohort study completed at Cleveland Clinic Ohio Hospitals from January 1, 2018, to October 1, 2025, that analyzed patients who received systemic alteplase for initial management of pulmonary embolism and were transitioned to apixaban prior to discharge. Results: A total of 205 patients received alteplase, with 58 patients meeting the inclusion criteria, including 50 patients receiving standard apixaban dosing and 8 receiving alternative dosing. Bleeding events were similar between groups: 8% versus 13%, P = .538; however, this study was underpowered. Death was more common in the alternative dosing group: standard group was 2% versus 25% in the alternative group; P = .047; however, no deaths were related to anticoagulation adverse events. Limitations to the study include small sample size and a single health system. Conclusion: Patients who received systemic thrombolytic therapy for pulmonary embolism had similar rates of bleeding when using standard apixaban dosing compared with alternative apixaban dosing.