What is the recommended duration of Eliquis (apixaban) therapy for a 39-year-old patient with total occlusion of the left posterior tibial and peroneal veins following a left malleolar fracture?

From the Guidelines

For a 39-year-old patient with deep vein thrombosis (DVT) involving total occlusion of the left posterior tibial, peroneal, and soleal veins following a left malleolar fracture, the recommended duration of Eliquis (apixaban) therapy is typically 3 months. This recommendation is based on the most recent and highest quality study available, which suggests that a minimum 3-month treatment phase of anticoagulation is recommended for patients with acute VTE who do not have a contraindication to anticoagulation 1. Since this DVT was provoked by trauma (fracture), and assuming there are no other risk factors for recurrence or bleeding, a 3-month course of Eliquis at the standard dose (5mg twice daily) would be appropriate for most patients. The choice of apixaban over other anticoagulants is supported by the recommendation to use apixaban, dabigatran, edoxaban, or rivaroxaban over VKA as treatment-phase anticoagulant therapy for patients with VTE (DVT of the leg or PE) 1. Key considerations in the management of this patient include:

• Monitoring for bleeding complications while on anticoagulation
• Ensuring the patient maintains adequate hydration and mobility as tolerated
• Weighing the risk of recurrent DVT against bleeding risk when deciding to discontinue therapy. It's also important to note that patients with significant residual clot or slow recovery may benefit from extended therapy, but this should be determined on a case-by-case basis. In general, the decision to extend or discontinue anticoagulation should be based on individual patient factors, including the risk of recurrence and the risk of bleeding, as well as the patient's overall health status and preferences.

From the Research

Treatment of DVT with Eliquis

• The patient is 39 years old and has a total occlusion of the left post-tibial, peroneal, and soleal veins after a left malleolar fracture.
• According to the study 2, apixaban (Eliquis) is approved for the acute treatment of deep-vein thrombosis (DVT) and pulmonary embolism (PE) as well as for the reduction in the risk of recurrent DVT and PE following initial therapy.
• The study 3 evaluated biomarkers of coagulation activity in relation to treatment dose, duration, and clinical outcome in patients with symptomatic DVT, and found that apixaban showed efficacy and safety similar to low-molecular-weight heparin followed by vitamin K antagonist (LMWH/VKA) for 12 weeks.

Duration of Eliquis Treatment

• The study 4 states that the efficacy of direct oral anticoagulants, including apixaban, is noninferior to warfarin, with an absolute rate of recurrent VTE or VTE-related death of 2.0% vs 2.2%.
• The study 5 recommends direct oral anticoagulants as first-line agents for eligible patients for treating venous thromboembolism, and suggests that the treatment duration should be individualized based on the patient's risk factors and clinical presentation.
• However, none of the studies provide a specific recommendation for the duration of Eliquis treatment in a patient with a total occlusion of the left post-tibial, peroneal, and soleal veins after a left malleolar fracture.

Considerations for Treatment

• The study 6 highlights the importance of thromboprophylaxis in patients with pelvic and acetabular fractures, and suggests that extended chemothromboprophylaxis on discharge may be necessary to prevent VTE.
• The patient's age and lack of other comorbidities may influence the treatment decision, as stated in the study 2, which notes that apixaban has not been extensively studied in patients over 75 years old, or those with cancer, low or high body weight, or poor renal function.