From the Guidelines
For a 94-year-old male with bilateral lower extremity DVT who is currently on Eliquis (apixaban) 5 mg twice daily and has stable clots on ultrasound, the best course of action is to continue the current anticoagulation therapy with Eliquis at the same dose. This recommendation is based on the most recent and highest quality evidence available, which suggests that for patients with DVT and no cancer, apixaban is a suitable option for long-term anticoagulant therapy 1. The patient's stable clots on ultrasound indicate that the current treatment is effective, and continuing the same regimen will help prevent further clot formation and potential pulmonary embolism. Given the patient's advanced age, it is essential to monitor for bleeding complications and consider dose adjustments if necessary, such as reducing to 2.5 mg twice daily if renal function is impaired or body weight is <60 kg. Regular monitoring through periodic ultrasounds and clinical evaluations is crucial to ensure the treatment's effectiveness and adjust the plan as needed. Additionally, the patient should be encouraged to maintain mobility, use compression stockings if not contraindicated, and elevate legs when sitting or lying down to reduce the risk of postthrombotic syndrome. The benefits of continued anticoagulation in preventing clot progression and potential pulmonary embolism outweigh the bleeding risks in most cases, even in elderly patients, as supported by the guidelines for antithrombotic therapy for VTE disease 1. It is also important to note that the use of compression stockings is not routinely recommended for preventing postthrombotic syndrome (PTS) in patients with DVT, as suggested by the guidelines 1. Overall, the goal is to balance the benefits of anticoagulation therapy with the risks of bleeding and other complications, and to prioritize the patient's morbidity, mortality, and quality of life. Key considerations in managing this patient include:
- Continuing apixaban 5 mg twice daily for at least 3-6 months
- Monitoring for bleeding complications and adjusting the dose as needed
- Encouraging mobility, compression stocking use, and leg elevation
- Regular follow-up with periodic ultrasounds and clinical evaluations
- Prioritizing the patient's morbidity, mortality, and quality of life in treatment decisions.
From the FDA Drug Label
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 Reduction of Risk of Stroke and Systemic Embolism in Patients with Nonvalvular Atrial Fibrillation 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.
The patient is a 94-year-old male with bilateral DVT, currently on Eliquis (apixaban) 5 mg twice a day. Given the patient's age (greater than or equal to 80 years), the recommended dose of apixaban is 2.5 mg twice daily. However, the patient is already on 5 mg twice daily, which is the dose for treatment of DVT and PE after the initial 7 days.
Since the clots have not moved, it indicates that the current treatment is effective in preventing the progression of the disease. However, considering the patient's age, it would be prudent to reduce the dose to 2.5 mg twice daily to minimize the risk of bleeding, as the patient is at a higher risk due to their age.
Key considerations:
- The patient's age puts them at a higher risk for bleeding complications.
- The current dose of 5 mg twice daily is effective in treating DVT and PE.
- Reducing the dose to 2.5 mg twice daily may be necessary to minimize the risk of bleeding. 2
From the Research
Patient Guidance for Bilateral DVT
The patient in question is a 94-year-old male with bilateral Deep Vein Thrombosis (DVT) of the lower extremities, currently on Eliquis (apixaban) 5 mg twice a day. The ultrasound shows that the clots have not moved, indicating stable clots.
- The patient's age and condition suggest that he belongs to a special population that has not been extensively studied in the context of apixaban use, as noted in 3.
- However, a study on apixaban in patients with atrial fibrillation and advanced age, low body weight, or high creatinine levels found that the 5 mg twice daily dose of apixaban is safe and efficacious for patients with only one dose-reduction criterion, which may be relevant to this patient's situation 4.
- There is limited direct evidence on the management of bilateral DVT in patients of this age group on apixaban.
- The use of vena cava filters has been explored in patients with DVT and pulmonary embolism, but the decision to place a filter should be made on a case-by-case basis, considering the patient's overall condition and risk factors 5, 6.
- A study on the safety and efficacy of apixaban in post-bariatric patients showed promising results, but its applicability to this patient's situation is limited due to differences in patient population and context 7.
Considerations for Management
Given the stable nature of the clots and the patient's current anticoagulation regimen, the following considerations may be relevant:
- Continuing the current dose of apixaban, as the patient's age and condition do not necessarily warrant a dose reduction, according to 4.
- Regular monitoring of the patient's condition, including ultrasound surveillance of the lower extremity deep veins, to assess the effectiveness of the current treatment plan.
- Evaluating the patient's overall risk factors for thromboembolic events and bleeding complications to inform management decisions.