From the Guidelines
For this 83-year-old male with bilateral pulmonary emboli (PEs), a history of ischemic stroke, and coronary artery disease (CAD) with stents on chronic Plavix (clopidogrel) and aspirin (ASA), I recommend transitioning from Lovenox to Eliquis (apixaban) 5 mg twice daily for at least 3 months for the acute PE treatment. Given his complex cardiovascular history, he should discontinue Plavix but continue low-dose aspirin (81 mg daily) alongside Eliquis for long-term management. After the initial 3-month treatment period for PE, he should be evaluated for extended anticoagulation, which would likely be recommended indefinitely given his risk factors. If the patient has reduced renal function (CrCl 15-29 mL/min), low body weight (≤60 kg), or is ≥80 years old with at least one additional risk factor, the Eliquis dose should be reduced to 2.5 mg twice daily 1. Regular monitoring for bleeding complications is essential, with particular attention to gastrointestinal and intracranial bleeding given his age and medication regimen. This approach balances the need to prevent recurrent venous thromboembolism while addressing his underlying cardiovascular conditions. Triple therapy (dual antiplatelet plus anticoagulant) should be avoided due to significantly increased bleeding risk, particularly in an elderly patient 1.
Some key considerations in this patient's management include:
- The need to minimize the duration of triple therapy to reduce bleeding risk, as recommended by the 2019 AHA/ACC/HRS focused update on the management of patients with atrial fibrillation 1
- The importance of monitoring renal function and adjusting the Eliquis dose accordingly, as outlined in the 2020 ACC expert consensus decision pathway for anticoagulant and antiplatelet therapy in patients with atrial fibrillation or venous thromboembolism undergoing percutaneous coronary intervention or with atherosclerotic cardiovascular disease 1
- The potential benefits of using a direct oral anticoagulant (DOAC) such as Eliquis, which has been shown to be effective in reducing the risk of stroke and systemic embolism in patients with atrial fibrillation, as well as in treating venous thromboembolism 1
Overall, the goal of this treatment approach is to balance the need to prevent recurrent venous thromboembolism and stroke with the need to minimize bleeding risk, while also taking into account the patient's complex cardiovascular history and comorbidities.
From the FDA Drug Label
4 Treatment of Pulmonary Embolism Apixaban tablets are indicated for the treatment of PE. 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 The recommended dose of apixaban tablets for most patients is 5 mg taken orally twice daily. The recommended dose of apixaban tablets is 2.5 mg twice daily in patients with 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 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. 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
For an 83-year-old male with a history of ischemic stroke and CAD with stents on chronic Plavix and ASA, currently admitted for bilateral PEs without RV strain, and hemodynamically stable, who will be transitioned from Lovenox to Eliquis (apixaban), the current guidelines and recommendations are:
- The patient should be started on 10 mg of apixaban twice daily for the first 7 days of therapy.
- After 7 days, the dose should be reduced to 5 mg twice daily for the treatment of PE.
- However, since the patient is greater than or equal to 80 years, the dose may need to be adjusted to 2.5 mg twice daily if the patient has other characteristics such as body weight less than or equal to 60 kg or serum creatinine greater than or equal to 1.5 mg/dL.
- For the reduction in the risk of recurrence of DVT and PE, the recommended dose is 2.5 mg twice daily after at least 6 months of treatment for DVT or PE 2.
From the Research
Anticoagulation Guidelines for Patient with Ischemic Stroke and CAD
The patient in question has a history of ischemic stroke and coronary artery disease (CAD) with stents, and is currently on chronic Plavix and ASA. Given the patient's current admission for bilateral pulmonary embolisms (PEs) without right ventricular strain and being hemodynamically stable, the transition from Lovenox to Eliquis is considered.
Short-Term Anticoagulation
- For patients with acute high-risk transient ischemic attack or minor ischemic stroke, dual antiplatelet therapy with aspirin and clopidogrel is recommended for 10-21 days 3.
- However, in the context of PE, the primary concern is anticoagulation rather than antiplatelet therapy. The transition to Eliquis, a direct oral anticoagulant (DOAC), is appropriate for the treatment of PE.
Long-Term Anticoagulation
- For long-term anticoagulation in patients with a history of ischemic stroke and CAD, the guidelines are less clear.
- Studies have shown that dual antiplatelet therapy with aspirin and clopidogrel may provide greater protection against subsequent stroke than monotherapy, but this is associated with an increased risk of bleeding 4, 5, 6.
- The use of DOACs, such as apixaban, has been shown to be effective in reducing the risk of recurrent stroke and is associated with a lower risk of intracranial hemorrhage compared to traditional anticoagulants 7.
- Given the patient's history of CAD and ischemic stroke, long-term anticoagulation with a DOAC, such as Eliquis, may be considered, but the decision should be individualized based on the patient's risk factors and bleeding risk.