From the Guidelines
The 87-year-old gentleman who developed a new onset DVT while on Eliquis 5 mg PO BID should be switched to a different anticoagulation regimen, such as therapeutic low molecular weight heparin (LMWH), due to the failure of his current anticoagulation therapy. The development of a new DVT despite being on therapeutic anticoagulation with Eliquis indicates a need for a change in management. According to the most recent guidelines, in patients with acute VTE who do not have a contraindication to anticoagulation, a minimum 3-mo treatment phase of anticoagulation is recommended 1.
Recommended Approach
- Switch to therapeutic LMWH, such as enoxaparin 1 mg/kg subcutaneously twice daily, to provide more predictable anticoagulation with less reliance on hepatic metabolism and renal clearance compared to direct oral anticoagulants like Eliquis.
- Conduct a thorough evaluation for underlying malignancy if not recently performed, as occult cancer can contribute to anticoagulation resistance.
- Assess medication adherence to ensure the patient has been taking Eliquis as prescribed.
- Consider laboratory testing for antiphospholipid syndrome.
Long-term Management
- Once stabilized on LMWH, refer the patient to a hematologist for consideration of long-term anticoagulation management.
- Long-term management might include continuing LMWH or potentially transitioning to a different oral anticoagulant, taking into account the patient's risk factors and the latest guidelines 1.
- The choice of anticoagulant should be based on the patient's individual risk factors, including the risk of recurrent VTE and the risk of anticoagulant-related bleeding.
Rationale
The rationale for switching to LMWH is that it provides more predictable anticoagulation with less reliance on hepatic metabolism and renal clearance compared to direct oral anticoagulants like Eliquis, potentially offering better protection against recurrent thrombosis in patients who have failed standard therapy. Additionally, the latest guidelines recommend the use of LMWH or fondaparinux over IV UFH in patients with acute VTE initiated with a parenteral agent 1.
From the Research
Next Steps for the Patient
The patient is an 87-year-old gentleman who has been on Eliquis 5 mg PO BID and developed a new onset DVT. The next steps for him would be:
- To assess the effectiveness of the current anticoagulation therapy and consider alternative options if necessary 2
- To evaluate the patient's risk factors for bleeding and thromboembolism, and adjust the treatment plan accordingly 3
- To consider the use of a different direct oral anticoagulant (DOAC) or warfarin, depending on the patient's specific clinical scenario and comorbidities 4, 5
- To monitor the patient's condition closely and adjust the treatment plan as needed to minimize the risk of recurrent VTE and bleeding complications 6, 3
Considerations for Anticoagulation Therapy
When considering anticoagulation therapy for this patient, the following factors should be taken into account:
- The patient's age and comorbidities, which may affect the risk of bleeding and thromboembolism 5
- The patient's renal function, which may affect the clearance of the anticoagulant and increase the risk of bleeding 4
- The patient's history of DVT, which may affect the choice of anticoagulant and the duration of treatment 2
- The availability of reversal agents for the anticoagulant, in case of major bleeding 3
Treatment Options
The treatment options for this patient would include:
- Continuing the current dose of Eliquis, with close monitoring of the patient's condition and adjustment of the treatment plan as needed 4
- Switching to a different DOAC, such as rivaroxaban or apixaban, depending on the patient's specific clinical scenario and comorbidities 5, 2
- Using warfarin, which may be preferred in certain clinical scenarios, such as patients with prosthetic valves or antiphospholipid syndrome 5