From the Guidelines
Starting a patient on Eliquis (apixaban) for a distal deep vein thrombosis (DVT) after a recent cesarean section is generally not recommended as first-line therapy. Instead, low molecular weight heparin (LMWH) such as enoxaparin is preferred for postpartum thrombosis treatment, as suggested by recent guidelines 1. The typical regimen would be enoxaparin 1 mg/kg twice daily for at least 6 weeks postpartum and a minimum total treatment duration of 3 months. Apixaban is not ideal in this scenario because it has limited safety data in the postpartum period, especially for breastfeeding mothers. There are concerns about potential secretion into breast milk, though recent data suggests minimal transfer. Additionally, the postpartum state represents a unique hypercoagulable condition where LMWH has been more extensively studied 1. If LMWH is contraindicated or not feasible, consultation with both hematology and obstetrics specialists would be advisable before considering apixaban. The patient should also receive appropriate counseling about the risks and benefits of anticoagulation therapy during this period, including bleeding risks and the importance of adherence to the prescribed regimen. Some key points to consider when making this decision include:
- The patient's recent history of cesarean section and the associated hypercoagulable state
- The limited safety data for apixaban in the postpartum period
- The preference for LMWH in postpartum thrombosis treatment
- The importance of counseling the patient on the risks and benefits of anticoagulation therapy. It's also important to note that the American College of Chest Physicians clinical practice guideline suggests against bridging with a therapeutic-dose heparin regimen, but does not preclude the use of a low-dose heparin regimen to decrease the risk for post-operative VTE 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Starting Eliquis for Distal Deep Vein Thrombosis after Cesarean Section
- The provided studies do not directly address the use of Eliquis (apixaban) for distal deep vein thrombosis (DVT) after a cesarean section.
- However, the studies discuss the use of low molecular weight heparin (LMWH) for thromboprophylaxis after cesarean section, which may be relevant to the decision to start a patient on Eliquis.
- A study from 2019 2 found that enoxaparin administration within 24 hours of cesarean section appears to be reasonable, regardless of epidural anesthesia.
- Another study from 2012 3 found that LMWH thromboprophylaxis after elective cesarean section has a sustained effect in reducing excess thrombin production.
- A study from 2001 4 compared the antithrombotic properties of three LMWHs (dalteparin, enoxaparin, and tinzaparin) after cesarean section and found that they differ in their effects on hemostatic parameters.
- A pilot study from 2001 5 found that LMWH (dalteparin) as prophylaxis after cesarean section is feasible and may reduce the risk of venous thrombotic events.
- A more recent study from 2023 6 found that low molecular weight heparin combined with pneumatic pressure therapy significantly reduces the incidence of lower limb deep vein thrombosis after cesarean section.
Considerations for Starting Eliquis
- The decision to start a patient on Eliquis after a cesarean section should be based on individual patient factors and clinical guidelines.
- The studies provided do not directly address the safety and efficacy of Eliquis in this setting, but they do provide information on the use of LMWH for thromboprophylaxis after cesarean section.
- It is essential to consider the patient's risk factors for venous thromboembolism, as well as any potential contraindications to anticoagulant therapy, before starting Eliquis.