What to do if a patient on Eliquis (apixaban) develops another Deep Vein Thrombosis (DVT) while on therapy?

From the Guidelines

If a patient on Eliquis (apixaban) develops another DVT while on therapy, the recommended approach is to switch to a different anticoagulant, typically low molecular weight heparin (LMWH) such as enoxaparin (Lovenox) at a therapeutic dose of 1 mg/kg twice daily. This decision is based on the most recent guidelines from the American Society of Hematology, which suggest that recurrent thrombosis while on a direct oral anticoagulant may indicate the need for a different anticoagulation strategy 1.

When managing a patient with recurrent DVT on Eliquis, it's crucial to:

• Confirm the recurrent DVT through appropriate imaging
• Evaluate for potential underlying causes of anticoagulation failure, including medication non-adherence, drug interactions, cancer, or antiphospholipid syndrome
• Consider increasing the apixaban dose to 10 mg twice daily, though this is off-label and should be decided on a case-by-case basis
• Alternatively, consider warfarin with a target INR of 2.5-3.5 for long-term management
• Ensure the patient was taking Eliquis correctly (twice daily dosing) and address any modifiable risk factors

The American Society of Hematology 2020 guidelines for management of venous thromboembolism suggest that the standard dose or the lower dose of rivaroxaban or apixaban may be used for the secondary prevention of VTE, but the decision should be individualized based on the patient's risk of recurrence and bleeding 1. However, in the case of recurrent DVT while on Eliquis, switching to a different anticoagulant is often the preferred approach to minimize the risk of further clot formation.

It's also important to note that the ASH guideline panel's recommendations are based on moderate certainty in the evidence of effects, and additional research is necessary to identify which subsets of patients can safely use a lower-dose DOAC and which patients should be maintained on a standard dose 1.

From the FDA Drug Label

To reduce the risk of thrombotic events, consider coverage with another anticoagulant if apixaban is discontinued for a reason other than pathological bleeding or completion of a course of therapy. Apixaban is indicated for the treatment of DVT and PE, and for the reduction in the risk of recurrent DVT and PE following initial therapy.

The patient should be evaluated for the cause of the recurrent DVT while on apixaban therapy. Consideration should be given to increasing the dose of apixaban or switching to another anticoagulant, but the FDA label does not provide specific guidance on this scenario. The decision to modify the patient's anticoagulation regimen should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 2. Key considerations include:

• The risk of thrombotic events with premature discontinuation of apixaban
• The need for coverage with another anticoagulant if apixaban is discontinued
• The importance of evaluating the patient for the cause of the recurrent DVT It is essential to weigh the benefits and risks of different anticoagulation regimens and to consider consultation with a specialist if necessary.

From the Research

Management of Recurrent DVT in Patients on Eliquis

• If a patient on Eliquis (apixaban) develops another Deep Vein Thrombosis (DVT) while on therapy, the approach to management should consider the individual's risk factors for recurrence and bleeding complications 3.
• The decision to continue or modify anticoagulation therapy should be based on the patient's intrinsic risk of having a new episode of VTE and the risk of bleeding complications 3, 4.
• Apixaban has been shown to be effective in reducing the incidence of recurrent VTE, with a lower risk of major bleeding compared to traditional anticoagulants such as warfarin 5, 6.
• In patients with cancer-associated VTE, apixaban has been found to be noninferior to dalteparin, with no increased risk of major bleeding 6.

Considerations for Long-term Anticoagulation

• Long-term anticoagulation may be preferable for patients with a high risk of recurrence, such as those with antiphospholipid antibody syndrome 7.
• The duration of anticoagulant treatment should be individualized, taking into account the patient's risk factors and the benefits and risks of continued therapy 3, 4.
• Regular monitoring and reassessment of the patient's risk-benefit profile are essential to determine the optimal duration of anticoagulation 3, 4.

Special Populations

• In patients with cancer, apixaban may be a suitable alternative to traditional anticoagulants, with a lower risk of bleeding complications 6.
• However, more research is needed to fully understand the benefits and risks of apixaban in special populations, such as patients with renal impairment or those with a history of heparin-induced thrombocytopenia 4.