From the Guidelines
The duration of anticoagulation therapy with Eliquis (apixaban) for pulmonary embolism should be at least 3 months for patients with a first provoked PE, and longer treatment of at least 6-12 months or indefinite therapy may be necessary for patients with unprovoked PE or those with ongoing risk factors. The decision to extend treatment beyond the initial period should be based on an individualized assessment of the patient's bleeding risk versus the risk of recurrent thrombosis, as recommended by the 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism 1. Factors favoring extended treatment include unprovoked PE, recurrent VTE, active cancer, antiphospholipid syndrome, or certain thrombophilias.
According to the guidelines, therapeutic anticoagulation for more than 3 months is recommended for all patients with PE, and extended oral anticoagulation of indefinite duration should be considered for patients with a first episode of PE and no identifiable risk factor, or those with a first episode of PE associated with a persistent risk factor other than antiphospholipid antibody syndrome 1. The guidelines also suggest that 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.
Regular reassessment of the risk-benefit balance is essential throughout treatment, as bleeding risk must be weighed against the risk of recurrent PE, which can be life-threatening, as noted in the 2020 European Heart Journal article 1. Patients should maintain regular follow-up appointments to evaluate treatment effectiveness and monitor for complications. The 2021 Chest guideline also recommends considering indefinite anticoagulation in patients with initial unprovoked PE, PE provoked by a persistent risk factor other than APS, and in patients with PE associated with a minor transient or reversible risk factor 1.
Key considerations in determining the duration of anticoagulation therapy include:
- The presence of transient or reversible risk factors
- The presence of persistent risk factors
- The patient's bleeding risk
- The patient's risk of recurrent thrombosis
- The patient's preference for treatment duration and dose.
By considering these factors and following the guidelines, clinicians can make informed decisions about the duration of anticoagulation therapy with Eliquis (apixaban) for patients with pulmonary embolism, with the goal of minimizing the risk of recurrent thrombosis while also minimizing the risk of bleeding complications.
From the FDA Drug Label
1.4 Treatment of Pulmonary Embolism Apixaban tablets are indicated for the treatment of PE.
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 ... 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.
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 patient with pulmonary embolism (PE) should continue anticoagulation therapy with Eliquis (apixaban) for at least 6 months after diagnosis, with a dose of 10 mg twice daily for the first 7 days, then 5 mg twice daily. After 6 months, the dose can be reduced to 2.5 mg twice daily to reduce the risk of recurrence of DVT and PE 2.
From the Research
Duration of Anticoagulation Therapy with Eliquis (Apixaban) for Pulmonary Embolism (PE)
The duration of anticoagulation therapy with Eliquis (apixaban) for patients with pulmonary embolism (PE) depends on various factors, including the individual risk of PE recurrence and the risk of bleeding 3, 4, 5.
- Initial Treatment: All patients with PE require therapeutic anticoagulation for at least three months 3, 5.
- Risk of Recurrence: The decision to extend anticoagulation is based on the risk of recurrence, which is related to the features of the index PE event 3, 4, 5.
- Patients with a strong transient risk factor have a low risk of recurrence and can usually discontinue anticoagulation after three months 3, 4, 5.
- Patients with a strong persistent risk factor, such as active cancer, have a high risk of recurrence and should receive anticoagulant treatment of indefinite duration 3, 4, 5.
- Bleeding Risk: The risk of bleeding is also an important consideration in deciding the duration of anticoagulation 3, 4, 5.
- Non-Vitamin K Antagonist Oral Anticoagulants (NOACs): The current guidelines recommend the use of NOACs, such as apixaban, in preference to vitamin K antagonists (VKAs) for the treatment of PE 3.
- The favourable safety profile of NOACs, especially with reduced dosages, supports the consideration of extended oral anticoagulation of indefinite duration for patients with intermediate risk of recurrence 3.
In summary, the duration of anticoagulation therapy with Eliquis (apixaban) for patients with PE should be individualized based on the risk of recurrence and bleeding, with a minimum duration of three months and consideration of indefinite treatment for patients with high risk of recurrence or low risk of bleeding 3, 4, 5, 6, 7.