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 due to deep vein thrombosis (DVT) following a left malleolar fracture, and is repeat venous Doppler ultrasound necessary to assess DVT resolution?

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, I recommend continuing Eliquis (apixaban) for at least 3 months, as suggested by the American Society of Hematology 2020 guidelines for management of venous thromboembolism 1. The standard treatment duration for a provoked DVT (one with a clear cause like trauma/fracture) is 3 months, though some cases may warrant 6 months of therapy depending on risk factors and clinical response. Regarding follow-up imaging, a repeat venous Doppler ultrasound is not routinely necessary if the patient's symptoms improve and there are no complications, as stated in the antithrombotic therapy for VTE disease guideline 1. The decision to discontinue anticoagulation should be based primarily on clinical improvement rather than imaging findings, as residual thrombus on ultrasound doesn't necessarily indicate need for continued therapy. However, if the patient experiences persistent or worsening symptoms, a follow-up Doppler would be appropriate to assess for thrombus progression or complications. After completing the anticoagulation course, the patient should be monitored for any recurrent symptoms such as leg pain, swelling, or redness that might suggest DVT recurrence. The standard Eliquis dosing for DVT treatment is 10mg twice daily for 7 days followed by 5mg twice daily for the remainder of the treatment period, which effectively prevents thrombus extension while allowing the body's natural fibrinolytic system to gradually dissolve the existing clot. Some key points to consider in the management of this patient include:

• The patient's age and the presence of a clear precipitating factor (the left malleolar fracture) suggest a lower risk of recurrent VTE, which supports a shorter duration of anticoagulation 1.
• The use of Eliquis (apixaban) is appropriate for the treatment of DVT, as it has been shown to be effective in preventing recurrent VTE and has a favorable safety profile compared to other anticoagulants 1.
• Regular follow-up with the patient is crucial to monitor for any signs of recurrent VTE or anticoagulant-related complications, and to adjust the treatment plan as needed.

From the FDA Drug Label

1.3 Treatment of Deep Vein Thrombosis Apixaban tablets are indicated for the treatment of DVT.

2.1 Recommended Dose Treatment of DVT and PE The recommended dose of apixaban tablets is 10 mg taken orally twice daily for the first 7 days of therapy. After 7 days, the recommended dose is 5 mg taken orally twice daily.

1.5 Reduction in the Risk of Recurrence of DVT and PE Apixaban tablets are indicated to reduce the risk of recurrent DVT and PE following initial therapy.

2.1 Recommended Dose Reduction in the Risk of Recurrence of DVT and PE The recommended dose of apixaban tablets is 2.5 mg taken orally twice daily after at least 6 months of treatment for DVT or PE

The patient should be on Eliquis (apixaban) for at least 6 months for the treatment of DVT, and then the dose can be reduced to 2.5 mg twice daily for the reduction in the risk of recurrence of DVT. There is no direct information in the label regarding the need to repeat venous Doppler to assess resolution of the DVT 2.

From the Research

Duration of Eliquis Treatment

• The duration of Eliquis treatment for a 39-year-old patient with total occlusion of the left post-tibial, peroneal, and soleal veins after a left malleolar fracture is not explicitly stated in the provided studies 3, 4, 5, 6, 7.
• However, study 5 mentions that 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.

Need for Repeat Venous Doppler

• Study 4 suggests that optimal anticoagulation is key for preventing post-thrombotic syndrome (PTS), and that treatment of PTS is based on the use of elastic compression stockings (ECS) and lifestyle measures.
• Study 7 found that the rate of PTS development was lower in patients treated with direct oral anticoagulants (DOACs) compared to those treated with vitamin K antagonists (VKAs).
• There is no clear indication in the provided studies that repeat venous Doppler is necessary to assess the resolution of DVT, but it may be useful for monitoring the patient's condition and adjusting treatment as needed 3, 6.

Patient-Specific Considerations

• The patient's age (39 years old) and the fact that she has total occlusion of the left post-tibial, peroneal, and soleal veins after a left malleolar fracture should be taken into account when determining the duration of Eliquis treatment and the need for repeat venous Doppler 5, 7.
• Study 5 mentions that there are some populations in which the use of apixaban has not been extensively studied, such as patients with cancer, low or high body weight, or poor renal function, but this does not appear to be relevant to the patient in question.