What is the next step in management for a 68-year-old female patient with a deep vein thrombosis (DVT) in her right lower extremity, who has been on Eliquis (apixaban) 5 mg twice a day for 21 days, with a recent ultrasound showing the clot is still in place?

From the Guidelines

For a 68-year-old female with a persistent DVT after 21 days of appropriate apixaban therapy, the recommended next step is to continue the current treatment regimen of Eliquis (apixaban) 5 mg twice daily for at least three more months. Persistence of the clot on ultrasound at 21 days is not unusual, as DVT resolution can take weeks to months even with appropriate anticoagulation 1. The primary goal of anticoagulation is to prevent clot extension and embolization rather than immediate clot dissolution. According to the Chest guidelines, apixaban is recommended over VKA as treatment phase anticoagulant therapy for patients with acute VTE, including DVT of the leg 1.

The patient should be reassured that the medication is likely working as intended despite the clot's continued presence. A follow-up ultrasound should be scheduled in 1-2 months to monitor for gradual resolution. During this period, the patient should be encouraged to:

• Maintain mobility as tolerated
• Consider compression stockings if not contraindicated
• Elevate the affected leg when seated
• Report any worsening symptoms such as increased pain, swelling, or shortness of breath immediately

If the clot shows no signs of resolution after 3 months of therapy or if symptoms worsen despite treatment, further evaluation would be warranted, potentially including hematology consultation to assess for underlying hypercoagulable conditions or consideration of alternative anticoagulation strategies 1. The decision to extend anticoagulation should be based on the patient's individual risk factors and the presence of transient or persistent risk factors for VTE 1.

From the FDA Drug Label

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.

The patient has been on Eliquis (apixaban) 5 mg twice a day for 21 days, which is the recommended dose after the initial 7 days of therapy.

• The patient's current dose is appropriate for the treatment of DVT.
• The fact that the clot is still in place after 21 days of treatment does not necessarily indicate a need for a dose adjustment, as the resolution of the clot is not solely dependent on the anticoagulant therapy.
• Continue the current treatment with Eliquis 5 mg twice a day and monitor the patient's condition closely, including regular follow-up ultrasounds to assess the resolution of the clot.
• Consider consulting with a specialist, such as a hematologist or vascular medicine specialist, for further guidance on the management of the patient's DVT 2.

From the Research

Patient Management

The patient has been on Eliquis (apixaban) 5 mg twice a day for 21 days for a deep vein thrombosis (DVT) in her right lower extremity, and a recent ultrasound shows the clot is still in place. The next steps in management should be based on the estimated individual risk for recurrent VTE and the risk of bleeding complications.

Treatment Duration

• According to 3, all patients with acute VTE should receive oral anticoagulant treatment for three months.
• 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, as stated in 4.
• The study 5 suggests that rivaroxaban, an oral factor Xa inhibitor, may provide a simple, fixed-dose regimen for treating acute DVT and for continued treatment.

Dose Adjustment

• There is limited data on dose adjustment of apixaban for secondary prophylaxis of VTE. However, study 6 suggests that low-dose apixaban or rivaroxaban may be used as secondary prophylaxis of upper extremity DVT in patients with persistent thrombotic risk or without affected vein recanalization.
• Study 7 found that low-dose apixaban (2.5 mg twice daily) seems safe after 6 months of full-dose treatment for secondary prophylaxis of VTE in cancer patients.

Recommendations

• Continue apixaban 5 mg twice a day for the recommended 3 months, as suggested by 3 and 4.
• After 3 months, reassess the patient's risk for recurrent VTE and bleeding complications to determine if indefinite anticoagulation is necessary, as recommended by 3 and 4.
• Consider low-dose apixaban (2.5 mg twice daily) as an option for secondary prophylaxis if the patient has a high risk of recurrence and a low risk of bleeding, based on the findings of 6 and 7.