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 typically 3 months, but this may be extended to 6 months depending on the patient's recovery and risk factors. Regarding follow-up imaging,

• a repeat venous Doppler ultrasound is not routinely necessary to document clot resolution if the patient is responding well to treatment with improving symptoms,
• however, if the patient has persistent symptoms or there are concerns about treatment efficacy,
• a follow-up Doppler at 3 months may be helpful to guide decisions about continuing or discontinuing anticoagulation, as noted in the antithrombotic therapy for VTE disease: second update of the chest guideline and expert panel report 1. The decision to extend treatment beyond 3 months should be based on an individualized assessment of the patient's risk of recurrence versus bleeding risk. Since this DVT was provoked by trauma (malleolar fracture), once the patient has fully recovered from the fracture and regained normal mobility,
• the risk of recurrent DVT decreases substantially,
• making extended anticoagulation potentially unnecessary unless other risk factors are present, as suggested by the American Society of Hematology 2020 guidelines for management of venous thromboembolism 1. Key factors to consider in the decision to extend anticoagulation include the patient's overall health, mobility, and presence of other risk factors for VTE, such as inherited thrombophilia or family history of VTE. Ultimately, the treatment plan should be tailored to the individual patient's needs and risk profile, with regular follow-up and reassessment to ensure the best possible outcomes.

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 Anticoagulation Therapy

• The duration of therapeutic-dose anticoagulation for most DVTs is considered to be at least 3 to 6 months, as stated in the revised AWMF S2k guidelines on Diagnostics and Therapy of Venous Thrombosis and Pulmonary Embolism 3.
• For a 39-year-old patient with a left malleolar fracture and total occlusion of the left post-tibial and peroneal veins, the recommended duration of anticoagulation therapy with Eliquis would likely be in line with these guidelines.
• However, the decision to extend or shorten the duration of anticoagulation therapy should be made on an individual basis, taking into account the patient's risk of recurrent VTE and bleeding risk, as well as their personal preferences 3.

Repeat Venous Doppler to Assess Resolution of DVT

• The need to repeat venous Doppler to assess the resolution of DVT is not explicitly stated in the provided studies.
• However, it is generally recommended to monitor patients with DVT for signs of resolution and to assess the risk of recurrent VTE, which may involve repeat imaging studies such as venous Doppler 3, 4.
• The decision to repeat venous Doppler should be made on a case-by-case basis, taking into account the individual patient's risk factors and clinical presentation.

Management of DVT in Trauma Patients

• Trauma patients are at increased risk of VTE, and pharmacologic VTE prophylaxis is a critical component of optimal trauma care 5, 6.
• The American Association for the Surgery of Trauma and the American College of Surgeons-Committee on Trauma have developed consensus recommendations for VTE prophylaxis in trauma patients, which include standardized medication dosing and evidence-based, prompt VTE prophylaxis in high-risk traumatic injuries 6.
• Apixaban (Eliquis) is an oral, direct factor Xa inhibitor that is approved for the acute treatment of DVT and pulmonary embolism, as well as for the reduction in the risk of recurrent DVT and PE following initial therapy 7.