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This information is intended for US healthcare professionals to access current scientific information about J&J Innovative Medicine products. It is prepared by Medical Information and is not intended for promotional purposes, nor to provide medical advice.

XARELTO® (rivaroxaban)

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American Geriatric Society 2023 Beers Criteria

Last Updated: 11/12/2024

SUMMARY

On May 4, 2023, the American Geriatric Society (AGS) published the Updated AGS Beers Criteria^® for Potentially Inappropriate Medication Use in Older Adults, in which the recommendation for (XARELTO) rivaroxaban changed from “use with caution” to “avoid for long-term treatment” in older adults with nonvalvular atrial fibrillation (NVAF) or venous thromboembolism (VTE).¹

The inclusion of rivaroxaban in the same category as warfarin (ie, as a medication to be avoided in the older adults) is not supported by the available evidence from randomized controlled trials (RCTs).²^-⁵ Additional information is highlighted below for your consideration. A letter to the editor⁶ and a reply from AGS⁷ are also available.

The updated 2023 Beers recommendation directly conflicts with the use of XARELTO in the elderly, as described in the current Food and Drug Administration (FDA)-approved United States Prescribing Information (USPI).⁸
- Clinical studies for rivaroxaban established robust efficacy and safety across 11 indications, including a consistent, positive benefit-risk profile in older adults with NVAF and VTE.
- Of the total number of adult patients in clinical trials for approved indications of XARELTO (N=64,943), 64% were ≥65 years old, with 27% being ≥75 years old. In clinical trials, the efficacy of XARELTO in the elderly (≥65 years old) was similar to that seen in patients <65 years old. Both thrombotic and bleeding event rates were higher in these older patients.
The updated 2023 Beers recommendation primarily utilized observational data and network meta-analyses.¹
- Conclusive inferences regarding differences among non-vitamin K direct oral anticoagulants (DOACs) cannot be drawn because no head-to-head RCTs have been conducted.

In contrast to the AGS Beers Criteria, guidelines issued by several professional societies endorse the use of rivaroxaban for NVAF and VTE and do not differentiate among DOACs. These guidelines recommend that selection of an anticoagulant should be based on the absolute and relative risks of stroke and bleeding for each individual patient, in addition to the cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics.

Medical societies that recommend the use of rivaroxaban for NVAF and VTE include but are not limited to those presented in Table: AF: Summary of Rivaroxaban Recommendations Within Medical Organization Guidelines and Table: VTE: Summary of Rivaroxaban Recommendations Within Medical Organization Guidelines.

Rivaroxaban (and all DOACs) should be “used with caution” in older adults given the positive benefit-risk profile of rivaroxaban vs warfarin in RCTs; the lack of head-to-head RCTs for rivaroxaban vs other DOACs; and the need to use caution with all anticoagulants, given their potential for causing an expected increase in the bleeding risk.

The updated Beers recommendation may result in significant, irreversible patient harm following deprescribing, nonmedical switching, or otherwise transitioning to other anticoagulants. Data from the 23,882-patient, GARFIELD AF global anticoagulant registry demonstrated that oral anticoagulant discontinuation for 7 or more days resulted in a 121% increase in stroke/systemic embolism, an 85% increase in myocardial infarction, and a 62% increase in all-cause mortality compared with when there was no such discontinuation, irrespective of whether oral anticoagulants were restarted or not.⁹

Additional Information

Additional information listing statement excerpts from the Beers Criteria Guidelines is presented in Table: Statement Excerpts From the Beers Criteria Guidelines.⁶

Table: Statement Excerpts From the Beers Criteria Guidelines⁶

Rivaroxaban may be a reasonable option in select circumstances.
The criteria are a blunt instrument, and it is not possible to delineate all specialized use cases and possible exceptions to the criteria.
Prescribing for older adults is often a complex endeavor involving consideration of many factors, particularly the preferences and goals of the older person and their family.
Medications listed in the Beer’s Criteria are potentially inappropriate, not definitely inappropriate.
Use of a medication with a recommendation to “avoid” is not an absolute contraindication, but rather a situation that calls for shared decision-making between the patient and their provider, with considerations for patient preferences, financial situation, and goals of care.

Table: AF: Summary of Rivaroxaban Recommendations Within Medical Organization Guidelines¹^,¹⁰^-¹⁸

Organization	Guideline Title	Summary of DOAC Recommendation	Excludes Rivaroxaban in Comparison to Other DOACs	Highest LOE for the Recommendation
AGS	American Geriatrics Society 2023 Updated AGS Beers Criteria^® for Potentially Inappropriate Medication Use in Older Adults¹	The recommendation for rivaroxaban has changed from “use with caution” to “avoid” for long-term treatment of NVAF and VTE, with the rationale being that observational studies and network meta-analyses have found this drug to confer a higher risk of major and gastrointestinal bleeding in older adults than that conferred by other DOACs, particularly apixaban but also dabigatran (COR, strong; LOE, moderate). The panel recognizes that there may be circumstances when rivaroxaban may be a reasonable choice, including for other clinical conditions and in special circumstances (such as when a once-daily DOAC is necessary to facilitate medication adherence), and that all DOACs confer a lower risk of intracranial hemorrhage than does warfarin.	Yes	Observational studies/network meta-analysis
AHA/ACC/HRS	2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines¹⁰	Anticoagulants are recommended for patients with AF and an estimated annual thromboembolic risk of ≥2% (eg, CHA₂DS₂-VASc score of ≥2 in men or ≥3 in women) to prevent stroke and systemic thromboembolism (COR, 1; LOE, A). DOACs are recommended over warfarin in patients with AF who are candidates for anticoagulation, except those with a history of moderate-to-severe rheumatic mitral stenosis or those with a mechanical heart valve (COR, 1; LOE, A).	No	RCT
AHA/ASA	2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association¹¹	OAC (such as with apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin) is recommended to reduce the risk of recurrent stroke in patients with NVAF and stroke or TIA (COR, 1; LOE, A). In patients with stroke or TIA and AF who do not have moderate-to-severe mitral stenosis or a mechanical heart valve, apixaban, dabigatran, edoxaban, or rivaroxaban is recommended in preference to warfarin to reduce the risk of recurrent stroke (COR, 1; LOE, BENEFIT-RISK).	No	RCT
AAFP	2017 Pharmacologic Management of Newly Detected Atrial Fibrillation: Updated Clinical Practice Guideline From the American Academy of Family Physicians¹²	The AAFP strongly recommends that patients with AF receive chronic anticoagulation unless they are at a low risk of stroke (CHADS₂ score <2) or have specific contraindications (strong recommendation, high-quality evidence). The choice of anticoagulation therapy should be based on patient preferences and patient history. Options for anticoagulants may include warfarin, apixaban, dabigatran, edoxaban, and rivaroxaban.	No	RCT
AAN	2014 Summary of Evidence-Based Guideline Update: Prevention of Stroke in Nonvalvular Atrial Fibrillation: Report of the Guideline Development Subcommittee of the American Academy of Neurology¹³	Patients with NVAF are at a high risk for ischemic stroke; the risk is the highest if patients have suffered a TIA or stroke (RELA). Our review indicates that several anticoagulant medications decrease the risk of ischemic stroke or of recurrent ischemic stroke in patients with NVAF (EVID). In clinical trials, new oral anticoagulants were noninferior or superior to warfarin for reducing stroke (EVID); in most patients, the reduction in ischemic stroke risk outweighed the risk of bleeding complications (RELA).¹³ To reduce the risk of stroke or subsequent stroke in patients with NVAF judged to require oral anticoagulants, clinicians should choose 1 of the following options (level B): Warfarin, target INR 2.0-3.0 Dabigatran 150 mg twice daily (if CrCl is >30 mL/min) Rivaroxaban 15 mg/day (if CrCl is 30-49 mL/min) or 20 mg/day Apixaban 5 mg twice daily (if serum creatinine is <1.5 mg/dL) or 2.5 mg twice daily (if serum creatinine is >1.5 and <2.5 mg/dL and body weight is <60 kg or age is at least 80 years [or both]) Triflusal 600 mg plus acenocoumarol, target INR 1.25-2.0 (patients at a moderate stroke risk mostly in developing countries) Clinicians should routinely offer oral anticoagulants to elderly patients (aged >75 years) with NVAF if there is no history of recent unprovoked bleeding or intracranial hemorrhage (level B).	No	RCT
CCS	The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation¹⁴	We recommend most patients should receive a DOAC (apixaban, dabigatran, edoxaban, or rivaroxaban) in preference to warfarin when OAC therapy is indicated for patients with NVAF (strong recommendation, high-quality evidence). We recommend that OAC therapy be prescribed for most frail elderly patients with AF (strong recommendation; moderate-quality evidence).	No	RCT
CHEST	2018 Antithrombotic Therapy for Atrial Fibrillation CHEST Guideline and Expert Panel Report¹⁵	In patients with AF who are eligible for OAC therapy, we recommend NOACs over VKAs (strength of recommendation, strong; quality of evidence, moderate).	No	RCT
ESC	2020 ESC Guidelines for the Diagnosis and Management of Atrial Fibrillation Developed in Collaboration With the European Association for Cardio-Thoracic Surgery (EACTS)¹⁶	For stroke prevention in patients with AF who are eligible for OAC therapy, NOACs are recommended in preference to VKAs, excluding patients with mechanical heart valves or moderate-to-severe mitral stenosis (COR, 1; LOE, A). Elderly and frail patients with AF: older people are less likely to receive OACs despite sufficient evidence supporting the use of OACs in this population. Frailty, comorbidities, and an increased risk of falls do not outweigh the benefits of OACs, given the small absolute risk of bleeding in anticoagulated elderly patients. Evidence from RCTs, meta-analyses, and large registries supports the use of OACs in this age group. Antiplatelets are neither more effective nor safer than warfarin and may even be harmful, whereas NOACs appear to have a better overall risk-benefit profile compared with warfarin. Prescribing a reduced dose of OACs is less effective in preventing AF adverse outcomes.	No	RCT
ESO	2019 Antithrombotic Treatment for Secondary Prevention of Stroke and Other Thromboembolic Events in Patients With Stroke or Transient Ischemic Attack and Nonvalvular Atrial Fibrillation: A European Stroke Organisation Guideline¹⁷	In patients with nonvalvular AF and previous ischemic stroke or TIA, we recommend NOACs over VKAs for secondary prevention of all events (strength of recommendation, strong; quality of evidence, high). In elderly patients with nonvalvular AF and a history of ischemic stroke or TIA, we suggest NOACs over VKAs (strength of recommendation, weak; quality of evidence, low).	No	RCT
NICE	2021 National Institute for Health and Care Excellence (NICE). Atrial Fibrillation: Diagnosis and Management¹⁸	Offer anticoagulation with a direct-acting oral anticoagulant to people with AF and a CHA₂DS₂-VASc score of ≥2, considering the risk of bleeding. Apixaban, dabigatran, edoxaban, and rivaroxaban are recommended as options, when used in line with the criteria specified in the relevant NICE technology appraisal guidance. Based on the evidence and their experience, the committee decided not to recommend 1 direct-acting oral anticoagulant over the others, but instead decided to emphasize that treatment should be tailored to the person's clinical needs and preferences. Each anticoagulant has different risks and benefits that should be considered and fully discussed with the person as part of informed, shared decision making.	No	RCT
Abbreviations: AAFP, American Academy of Family Physicians; AAN, American Academy of Neurology; ACC, American College of Cardiology; ACCP, American College of Clinical Pharmacy; AF, atrial fibrillation; AGS, American Geriatrics Society; AHA, American Heart Association; ASA, American Stroke Association; CCS, Canadian Cardiovascular Society; CHA₂DS₂-VASc, congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 and sex category (female); CHEST, The American College of Chest Physicians; COR, Class of Recommendation; CrCl, creatinine clearance; DOAC, non-vitamin K direct acting oral anticoagulant; ESC, European Society of Cardiology; ESO, European Stroke Organisation; EVID, evidence-based conclusions for the systematic review; HRS, Heart Rhythm Society; INR, international normalized ratio; LOE, level of evidence; NICE, National Institute for Health and Care Excellence; NOAC, non-vitamin K antagonist oral anticoagulant; NVAF, nonvalvular atrial fibrillation; OAC, oral anticoagulation; RCT, randomized controlled trial; RELA, (strong evidence from) related conditions not systematically reviewed; TIA, transient ischemic attack; VKA, vitamin K antagonist; VTE, venous thromboembolism.

Table: VTE: Summary of Rivaroxaban Recommendations Within Medical Organization Guidelines¹^,¹⁹^-²⁵

Organization	Guideline Title	Summary of DOAC Recommendation	Excludes Rivaroxaban in Comparison to Other DOACs	Highest LOE for the Recommendation
AGS	American Geriatrics Society 2023 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults¹	The recommendation for rivaroxaban has changed from “use with caution” to “avoid” for long-term treatment of nonvalvular atrial fibrillation and VTE, with the rationale being that observational studies and network meta-analyses have found this drug to confer a higher risk of major and gastrointestinal bleeding in older adults than that conferred by other DOACs, particularly apixaban but also dabigatran (COR, strong; LOE, moderate). The panel recognizes that there may be circumstances when rivaroxaban may be a reasonable choice, including for other clinical conditions and in special circumstances (such as when a once-daily DOAC is necessary to facilitate medication adherence), and that all DOACs confer a lower risk of intracranial hemorrhage than does warfarin.	Yes	Observational studies/network meta-analysis
ASH	American Society of Hematology 2020 Guidelines for Management of Venous Thromboembolism: Treatment of Deep Vein Thrombosis and Pulmonary Embolism¹⁹	For patients with DVT and/or PE, the ASH guideline panel suggests using DOACs over VKAs (conditional recommendation based on moderate certainty in the evidence of effects). For patients with DVT and/or PE, the ASH guideline panel does not suggest 1 DOAC over another (conditional recommendation based on very low certainty in the evidence of comparative effects). For patients who will be treated with a DOAC, the ASH guideline panel does not suggest 1 medication over another, given the very low certainty in the evidence on comparative effects. However, for patients who will be taking a DOAC, there are differences that should be taken into consideration. For patients with DVT and/or PE who have completed primary treatment and will continue with a DOAC for secondary prevention, the ASH guideline panel suggests using standard-dose DOAC or lower-dose DOAC (conditional recommendation based on moderate certainty in the evidence of effects).	No	RCT
BTS	2018 British Thoracic Society Guideline for the Initial Outpatient Management of Pulmonary Embolism (PE)²⁰	Treatment of suspected/confirmed PE in the outpatient setting: Patients with confirmed PE being treated in the outpatient setting should be offered treatment with LMWH and dabigatran, LMWH and edoxaban, or a single-drug regimen (apixaban or rivaroxaban) (grade A). Patients with suspected PE being treated in the outpatient setting may be treated with apixaban or rivaroxaban pending diagnosis as an alternative to LMWH (grade D).	No	RCT
CHEST	2021 Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report²¹	In patients with VTE (DVT of the leg or PE), we recommend apixaban, dabigatran, edoxaban, or rivaroxaban over VKAs as treatment-phase (first 3 months) anticoagulant therapy (strong recommendation, moderate certainty evidence). In patients offered extended-phase anticoagulation, we suggest the use of reduced-dose apixaban or rivaroxaban over full-dose apixaban or rivaroxaban (weak recommendation; very low certainty evidence).	No	RCT
CMAJ	2015 Diagnosis and Management of Iliofemoral Deep Vein Thrombosis: Clinical Practice Guideline²²	For patients with acute iliofemoral DVT and no cancer, treatment with the following alternative regimens may be initiated: LMWH, switched to dabigatran after 1 week; rivaroxaban; or apixaban (I, B, strong, moderate).	No	RCT
ESC	2022 Second Consensus Document on Diagnosis and Management of Acute Deep Vein Thrombosis: Updated Document Elaborated by the ESC Working Group on Aorta and Peripheral Vascular Diseases and the ESC Working Group on Pulmonary Circulation and Right Ventricular Function²³	Initial and long-term DVT management in noncancer patients: NOACs should be preferred as the first-line anticoagulant therapy in absence of contraindications. Extended management (>first 3 months) of DVT (without PE): In the absence of contraindications, NOACs should be preferred as the first-line extended anticoagulant therapy in noncancer patients, except in patients with antiphospholipid syndrome.	No	RCT
ESC	2019 ESC Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism Developed in Collaboration With the European Respiratory Society (ERS): The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)²⁴	Recommendations for acute-phase treatment of intermediate- or low-risk PE: When oral anticoagulation is started in a patient with PE who is eligible for an NOAC (apixaban, dabigatran, edoxaban, or rivaroxaban), an NOAC is recommended in preference to a VKA (COR, 1; LOE, A). NOAC dose in extended anticoagulation: If extended oral anticoagulation is decided after PE in a patient without cancer, a reduced dose of NOACs apixaban (2.5 mg bid) or rivaroxaban (10 mg od) should be considered after 6 months of therapeutic anticoagulation (COR, 2a; LOE, A).	No	RCT
NICE	2020 National Institute for Health and Care Excellence (NICE). Venous Thromboembolic Diseases: Diagnosis, Management and Thrombophilia Testing²⁵	Anticoagulation treatment for confirmed DVT or PE: Offer either apixaban or rivaroxaban to people with confirmed proximal DVT or PE (but see recommendations 1.3.11 to 1.3.20 for people with any of the clinical features listed in recommendation 1.3.7). The committee was not confident that apixaban should be the only option for a DOAC and recommended apixaban and rivaroxaban as options. The committee recognized that apixaban or rivaroxaban might not be suitable for everyone; thus, they included options for treatment with LMWH followed by dabigatran or edoxaban or with LMWH with a VKA. Long-term anticoagulation for secondary prevention: Take into account the person's preferences and their clinical situation when selecting an anticoagulant for long-term treatment.	No	RCT
Abbreviations: AGS, American Geriatric Society; ASH, American Society of Hematology; bid, twice a day; BTS, British Thoracic Society; CHEST, The American College of Chest Physicians; CMAJ, Canadian Medical Association Journal; COR, class of recommendation; DOAC, non-vitamin K direct-acting oral anticoagulant; DVT, deep vein thrombosis; ESC, European Society of Cardiology; LMWH, low-molecular-weight heparin; LOE, level of evidence; NICE, National Institute for Health and Care Excellence; NOAC, non-vitamin K antagonist oral anticoagulant; od, once daily; PE, pulmonary embolism; RCT, randomized controlled trial; VKA, vitamin K antagonist; VTE, venous thromboembolism.

Literature Search

A literature search of MEDLINE^®, EMBASE^®, BIOSIS Previews^®, and DERWENT^® (and/or other resources, including internal/external databases) was conducted on 30 October 2024.

References

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1	By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081.
2	Graham DJ, Baro E, Zhang R, et al. Comparative stroke, bleeding, and mortality risks in older Medicare patients treated with oral anticoagulants for nonvalvular atrial fibrillation. Am J Med. 2019;132(5):596-604.
3	Han S, Han S, Suh HS, et al. Effectiveness and safety of non-vitamin K antagonist oral anticoagulants in patients with non-valvular atrial fibrillation: a nationwide, population-based study in Korea. J Arrhythm. 2021;37(5):1240-1249.
4	Lawal O, Aronow H, Shobayo F. Comparative effectiveness and safety of direct oral anticoagulants and warfarin in patients with atrial fibrillation and chronic liver disease: a nationwide cohort study. Circulation. 2023;147(10):782-794.
5	Lee SR, Choi EK, Kwon S, et al. Effectiveness and safety of contemporary oral anticoagulants among Asians with nonvalvular atrial fibrillation. Stroke. 2019;50(8):2245-2249.
6	Burnett AE, Barnes GD, Allen AL, et al. Comment on: 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(12):3951-3953.
7	Semla TP, Steinman MA. Reply to: Comment on: 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(12):3953-3954.
8	XARELTO (rivaroxaban) [Prescribing Information]. Titusville, NJ: Janssen Pharmaceuticals, Inc;https://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/XARELTO-pi.pdf
9	Cools F, Johnson D, Camm AJ, et al. Risks associated with discontinuation of oral anticoagulation in newly diagnosed patients with atrial fibrillation: results from the GARFIELD-AF Registry. J Thromb Haemost. 2021;19(9):2322-2334.
10	Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(1):e1-e156.
11	Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association. Stroke. 2021;52(7):e364-e467.
12	Frost JL, Campos-Outcalt D, Hoelting D, et al. Pharmacologic management of newly detected atrial fibrillation: updated clinical practice guideline from the American Academy of Family Physicians. Accessed May 2023. Available via: https://www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/a-fib-guideline.pdf
13	Culebras A, Messe SR, Chaturvedi S, et al. Summary of evidence-based guideline update: prevention of stroke in nonvalvular atrial fibrillation: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2014;82(8):716-724.
14	Andrade JG, Aguilar M, Atzema C, et al. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society comprehensive guidelines for the management of atrial fibrillation. Can J Cardiol. 2020;36(12):1847-1948.
15	Lip GYH, Keshishian AV, Li X. Comparative effectiveness and safety between non-VKA oral anticoagulants in non-valvular atrial fibrillation patients: a dose subgroup analysis of the ARISTOPHANES study. Eur Heart J. 2018;39(1):P2903.
16	Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2020;42(5):373-498.
17	Klijn CJ, Paciaroni M, Berge E, et al. Antithrombotic treatment for secondary prevention of stroke and other thromboembolic events in patients with stroke or transient ischemic attack and nonvalvular atrial fibrillation: a European Stroke Organisation guideline. Eur Stroke J. 2019;4(3):198-223.
18	Atrial fibrillation: diagnosis and management \| National Institute for Health and Care Excellence (NICE); 2021. Accessed 2024-11-07. Available via: https://www.nice.org.uk/guidance/ng196
19	Ortel TL, Neumann I, Ageno W, et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv. 2020;4(19):4693-4738.
20	Howard LSGE, Barden S, Condliffe R, et al. British Thoracic Society Guideline for the initial outpatient management of pulmonary embolism (PE). Thorax. 2018;73((Suppl. 2)):ii1-ii29.
21	Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic therapy for VTE disease: second update of the CHEST guideline and expert panel report. Chest. 2021;160(6):e545-e608.
22	Liu D, Peterson E, Dooner J, et al. Diagnosis and management of iliofemoral deep vein thrombosis: clinical practice guideline. CMAJ. 2015;187(17):1288-1296.
23	Mazzolai L, Ageno W, Alatri A, et al. Second consensus document on diagnosis and management of acute deep vein thrombosis: updated document elaborated by the ESC Working Group on aorta and peripheral vascular diseases and the ESC Working Group on pulmonary circulation and right ventricular function. Eur J Prev Cardiol. 2022;29(8):1248-1263.
24	Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41(4):543-603.
25	Venous thromboembolic diseases: diagnosis, management and thrombophilia testing \| National Institute for Health and Care Excellence (NICE); 2020. Accessed 2024-11-07. Available via: https://www.nice.org.uk/guidance/ng158