What is the treatment approach for an 84-year-old patient with a deep vein thrombosis (DVT) in the right upper extremity, currently on Plavix (clopidogrel) 75mg and Eliquis (apixaban) 5mg twice daily (BID)?

From the Guidelines

The patient should continue the current anticoagulation regimen while undergoing urgent evaluation by a vascular specialist or hematologist to determine the need for more aggressive intervention, such as catheter-directed thrombolysis or thrombectomy. For an 84-year-old patient with an upper extremity blood clot who is already on dual antithrombotic therapy (Plavix 75mg daily and Eliquis 5mg twice daily), it is crucial to assess the clot's severity and the patient's overall condition. The presence of a new clot despite being on therapeutic anticoagulation suggests potential issues such as medication non-adherence, drug-drug interactions, or an underlying hypercoagulable condition that requires further investigation 1.

Key considerations in managing this patient include:

• Evaluating the clot for occlusion and assessing the need for immediate intervention
• Investigating potential causes of the clot, including adherence to the current medication regimen and possible drug interactions
• Monitoring for symptoms of vascular compromise, such as pain, coldness, numbness, or color changes in the affected extremity
• Balancing the risk of clot progression against the risk of bleeding, particularly given the patient's advanced age and the use of dual antithrombotic therapy
• Regularly assessing renal function, as it impacts the dosing of Eliquis, especially in elderly patients 1.

Given the patient's age and the complexity of their condition, a multidisciplinary approach involving vascular specialists, hematologists, and possibly other healthcare professionals is essential to optimize outcomes and minimize risks. The goal is to prevent further clot progression, reduce the risk of recurrent thrombotic events, and maintain the patient's quality of life while minimizing the risk of anticoagulant-related bleeding complications.

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.

The patient is already on Eliquis (apixaban) 5mg BID, which is the recommended dose for the treatment of DVT after the initial 7 days. Considering the patient's age (84 years), the recommended dose of apixaban is 2.5 mg twice daily if they have at least two of the following characteristics:

• age greater than or equal to 80 years
• body weight less than or equal to 60 kg
• serum creatinine greater than or equal to 1.5 mg/dL However, since the patient's weight and serum creatinine are not provided, and they are already on 5mg BID, it is recommended to continue with the current dose of Eliquis (apixaban) 5mg BID and Plavix 75mg as prescribed, and monitor the patient closely for any signs of bleeding or thrombotic events 2.

From the Research

Treatment Approach

The patient is already on Plavix (clopidogrel) 75mg and Eliquis (apixaban) 5mg BID, which is a combination of antiplatelet and anticoagulant therapy.

• The combination of anticoagulant and antiplatelet therapy is more effective than antiplatelet therapy alone for the initial and long-term management of acute coronary syndromes, but increases the risk of bleeding 3.
• In patients with atrial fibrillation, switching from antiplatelet therapy to anticoagulants might be all that is required 3.

Bleeding Risk

• The combination of anticoagulant and antiplatelet therapy has been shown to increase the risk of bleeding, with a bleed rate of up to 27% in patients on triple therapy 4.
• The use of prasugrel versus clopidogrel and admission hemoglobin less than 12 mg/dL were identified as risk factors associated with bleeding in patients on triple antithrombotic therapy 4.
• The choice of oral anticoagulant did not impact bleeding rates in patients on triple antithrombotic therapy 4.

Management of Blood Clot

• Anticoagulation appears to be as effective as antiplatelet therapy for long-term management of acute coronary syndrome and stroke, and possibly peripheral artery disease, but causes more bleeding 3.
• The combination of aspirin, clopidogrel, and low-dose rivaroxaban has been approved for secondary prevention after acute coronary syndrome in some regions 5.
• Low-dose (2.5 mg twice daily) rivaroxaban on the other hand, is associated with a significantly higher efficacy on the occurrence of combined cardiovascular death, myocardial infarction, stroke, and of stent thrombosis 6.

Specific Considerations

• The patient's age and existing medication regimen should be taken into account when determining the best course of treatment.
• The risk of bleeding should be carefully weighed against the potential benefits of anticoagulant and antiplatelet therapy in this patient.
• Further studies are needed to identify the patient who will benefit most from combination therapy of NOAC and DAPT 6.