How long should a patient be on Eliquis (apixaban) after a bilateral pulmonary embolism (PE)?

From the Guidelines

Patients with bilateral pulmonary embolism should be on Eliquis (apixaban) for at least 3-6 months, and often require extended therapy beyond 6 months, possibly indefinitely, as the risk of VTE recurrence is lifelong 1. The decision to extend anticoagulation should be individualized, taking into account the patient's bleeding risk, whether the PE was provoked or unprovoked, and the presence of any persistent risk factors.

• Key factors to consider when deciding on the duration of anticoagulation include:
  • Whether the PE was provoked by a temporary risk factor or was unprovoked
  • The patient's bleeding risk, which should be assessed using prediction models 1
  • The presence of any persistent risk factors, such as antiphospholipid antibody syndrome
  • The patient's preference and ability to tolerate long-term anticoagulation
• The standard dosing for Eliquis is 10 mg twice daily for the first 7 days, followed by 5 mg twice daily for the remainder of treatment, but a reduced dose of 2.5 mg twice daily may be considered after 6 months of therapeutic anticoagulation 1.
• Regular follow-up with a healthcare provider is essential to assess treatment effectiveness, monitor for bleeding complications, and adjust the treatment plan as needed 1.
• Patients should be educated on the importance of adhering to their anticoagulation regimen, and the need for regular monitoring of their kidney function and bleeding risk.
• The patient's drug tolerance and adherence, hepatic and renal function, and bleeding risk should be reassessed at regular intervals, and the treatment plan adjusted accordingly 1.

From the FDA Drug Label

1.4 Treatment of Pulmonary Embolism Apixaban tablets are indicated for the treatment of PE.

2.4 Converting from or to apixaban ...

2 DOSAGE & ADMINISTRATION 2.1 Recommended Dose ... 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.

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 in the Risk of Recurrence of DVT and PE The recommended dose of apixaban tablets is 2.5 mg taken orally twice daily after at least 6 months of treatment for DVT or PE

The recommended duration of treatment with Eliquis (apixaban) for a bilateral pulmonary embolism (PE) is not explicitly stated in the FDA drug label. However, for the treatment of PE, the recommended dose is 10 mg twice daily for the first 7 days, followed by 5 mg twice daily. For the reduction in the risk of recurrence of DVT and PE, the recommended dose is 2.5 mg twice daily after at least 6 months of treatment for DVT or PE 2.

From the Research

Duration of Eliquis Treatment for Bilateral Pulmonary Embolism

The duration of Eliquis (apixaban) treatment for bilateral pulmonary embolism (PE) depends on various factors, including the risk of recurrence and the risk of bleeding.

• According to a study published in Blood 3, the decision to stop anticoagulants at 3 months or to treat indefinitely is dominated by the long-term risk of recurrence, and secondarily influenced by the risk of bleeding and by patient preference.
• A study published in Annals of internal medicine 4 found that patients with pulmonary embolism have a substantial risk for recurrence after discontinuation of oral anticoagulation, regardless of treatment duration.
• Another study published in Clinical therapeutics 5 found that the efficacy and tolerability of apixaban, dabigatran, rivaroxaban, and warfarin for extended VTE treatment were not significantly different.

Factors Influencing Treatment Duration

Several factors can influence the duration of Eliquis treatment for bilateral PE, including:

• Risk of recurrence: Patients with a high risk of recurrence may require indefinite anticoagulation 3, 4.
• Risk of bleeding: Patients with a high risk of bleeding may require a shorter treatment duration or a reduced dose of anticoagulant 3, 6.
• Patient preference: Patient preference can also play a role in determining the treatment duration 3.

Extended Reduced-Dose Apixaban

A recent study published in The New England journal of medicine 6 found that extended treatment with a reduced dose of apixaban (2.5 mg twice daily) was noninferior to full-dose apixaban (5.0 mg twice daily) for the prevention of recurrent venous thromboembolism in patients with active cancer.

• The study also found that the reduced dose led to a lower incidence of clinically relevant bleeding complications than the full dose.
• However, it is unclear whether these findings can be applied to patients with bilateral PE who do not have active cancer.