From the Guidelines
For patients with bilateral pulmonary embolism (PE) started on Eliquis (apixaban), routine follow-up imaging is generally not recommended unless there are concerning clinical developments, as stated in the 2019 ESC guidelines 1. Most patients should be monitored clinically rather than with repeat imaging. If symptoms persist or worsen after 5-7 days of appropriate anticoagulation therapy, or if new symptoms develop during treatment, follow-up imaging (typically CT pulmonary angiography) should be considered. The standard treatment regimen for PE with apixaban is 10 mg twice daily for the first 7 days, followed by 5 mg twice daily for at least 3 months, as recommended by the guidelines 1. During treatment, patients should be monitored for signs of clinical improvement such as decreased shortness of breath, reduced chest pain, and improved oxygen levels. The rationale for limited routine imaging is that anticoagulation prevents new clot formation while the body's natural fibrinolytic system gradually dissolves existing clots. Most PEs resolve without intervention beyond anticoagulation, and radiation exposure from repeated CT scans carries its own risks. However, patients with massive PE, hemodynamic instability, or those who received thrombolytic therapy may benefit from follow-up imaging at 1-3 months to assess for resolution and potential chronic thromboembolic pulmonary hypertension. Some key points to consider in the management of PE include:
- Therapeutic anticoagulation for > 3 months is recommended for all patients with PE 1
- Extended oral anticoagulation of indefinite duration should be considered for patients with a first episode of PE and no identifiable risk factor, or with a persistent risk factor other than antiphospholipid antibody syndrome 1
- If extended oral anticoagulation is decided after PE in a patient without cancer, a reduced dose of the NOACs apixaban (2.5 mg b.i.d.) or rivaroxaban (10 mg o.d.) should be considered after 6 months of therapeutic anticoagulation 1. It is essential to weigh the benefits and risks of continuing anticoagulation therapy and to reassess the patient's condition regularly, as recommended by the guidelines 1.
From the Research
Timing of Imaging Recheck after Bilateral PE Treatment with Eliquis
- The decision to recheck imaging after starting Eliquis (apixaban) for bilateral pulmonary embolism (PE) depends on various factors, including the patient's clinical probability of PE, D-dimer levels, and the presence of any complications 2.
- According to the study published in JAMA, patients with a high probability of PE should undergo chest imaging, and D-dimer testing is not necessary 2.
- The study published in Blood suggests that the treatment of venous thromboembolism (VTE) should generally be continued for either 3 months or indefinitely, depending on the long-term risk of recurrence and the risk of bleeding 3.
- There is no specific guidance on the timing of imaging recheck after starting Eliquis for bilateral PE, but it is recommended to monitor patients for signs of recurrence or complications, such as bleeding or thrombosis 4, 5.
- A case report published in BMJ case reports highlights the importance of monitoring patients on apixaban for potential complications, such as haematoma formation, which can cause small bowel intussusception 6.