What is the best management approach for a patient with a partially occlusive thrombus in the proximal superficial femoral vein who is currently anticoagulated with Eliquis (apixaban)?

From the Guidelines

For a patient with a partially occlusive thrombus in the proximal superficial femoral vein who is already on apixaban (Eliquis), the recommended approach is to continue the current anticoagulation therapy. The standard dosing for acute deep vein thrombosis (DVT) treatment with apixaban is 10 mg twice daily for 7 days, followed by 5 mg twice daily for at least 3 months 1. If the patient is already on this regimen, no dose adjustment is needed. Regular follow-up with duplex ultrasound at 1-3 months is recommended to assess thrombus resolution. The patient should be educated about the importance of medication adherence, elevation of the affected limb to reduce swelling, and wearing compression stockings (20-30 mmHg) during the day. They should also be monitored for signs of bleeding complications and advised to avoid NSAIDs and other medications that increase bleeding risk.

Regarding the question of starting lovenox (enoxaparin) while on Eliquis, it is not recommended to add lovenox to the current anticoagulation regimen with apixaban, as this may increase the risk of bleeding complications without providing additional benefits in preventing recurrent VTE 1. The current anticoagulation therapy with apixaban is effective in preventing thrombin formation and clot development, and the body's natural fibrinolytic system works to dissolve the existing clot.

Some key points to consider in the management of this patient include:

• The importance of medication adherence to prevent recurrent VTE
• Regular follow-up with duplex ultrasound to assess thrombus resolution
• Monitoring for signs of bleeding complications
• Avoiding NSAIDs and other medications that increase bleeding risk
• Educating the patient on the importance of elevation of the affected limb and wearing compression stockings to reduce swelling.

This approach is supported by the most recent and highest quality study available, which recommends continuing the current anticoagulation therapy with apixaban for patients with acute DVT 1.

From the FDA Drug Label

2.4 Converting from or to apixaban Switching from apixaban to anticoagulants other than warfarin (oral or parenteral): Discontinue apixaban and begin taking the new anticoagulant other than warfarin at the usual time of the next dose of apixaban

The patient is currently taking Eliquis (apixaban) and the question is whether to start Lovenox (enoxaparin) while on Eliquis. No direct information is provided in the label regarding concurrent administration of apixaban with other anticoagulants like Lovenox. However, the label does provide guidance on switching from apixaban to other anticoagulants. It is not recommended to start Lovenox while the patient is on Eliquis, as this would be concurrent administration, not switching. The best approach would be to consult with a healthcare professional for guidance on the management of the patient's condition. 2

From the Research

Treatment Approach

The patient is currently anticoagulated with Eliquis (apixaban) and has a partially occlusive thrombus in the proximal superficial femoral vein. The treatment approach for this patient can be guided by the following points:

• Apixaban is an effective and safe alternative to conventional treatment for venous thromboembolism (VTE) 3, 4, 5.
• Extended anticoagulation with apixaban reduces the risk of recurrent VTE without increasing the rate of major bleeding 3.
• Apixaban has been shown to be more effective than rivaroxaban in preventing recurrent VTE and major bleeding events 6.

Use of Lovenox with Eliquis

Regarding the use of Lovenox (enoxaparin) with Eliquis (apixaban), the following points should be considered:

• There is no direct evidence to support the use of Lovenox with Eliquis in the provided studies.
• However, a study comparing apixaban to enoxaparin/warfarin found that apixaban reduced all-cause hospitalizations and shortened the length of hospital stay in patients with acute VTE 7.
• It is essential to note that the use of two anticoagulants simultaneously may increase the risk of bleeding, and the decision to start Lovenox while the patient is on Eliquis should be made with caution and under close medical supervision.

Management Considerations

The management of the patient's condition should take into account the following:

• The patient's current anticoagulation therapy with Eliquis should be continued, and the dose should be adjusted according to the patient's response and renal function.
• Close monitoring of the patient's condition, including regular ultrasound assessments and laboratory tests, is crucial to ensure the effectiveness of the treatment and to minimize the risk of complications.
• The patient should be educated on the signs and symptoms of bleeding and VTE recurrence and instructed to seek medical attention immediately if any concerns arise.