What's the next step for a 65-year-old patient with a history of provoked Deep Vein Thrombosis (DVT) on Eliquis (apixaban) for 6 months, with a negative Doppler ultrasound and elevated D-dimer levels?

From the Guidelines

The next step for this 65-year-old patient with a history of provoked DVT who has completed 6 months of apixaban therapy, has a negative Doppler ultrasound but elevated D-dimer levels, would be to discontinue anticoagulation therapy. Since the DVT was provoked (meaning it occurred in the presence of a temporary risk factor) and the patient has completed the standard 3-6 month treatment course with apixaban, continuing anticoagulation is not routinely recommended, as suggested by the Chest guideline and expert panel report 1. The negative Doppler ultrasound confirms resolution of the clot. While the D-dimer is elevated, this test has low specificity in older adults and can be elevated for many reasons unrelated to active thrombosis. After discontinuing apixaban, the patient should be educated about signs and symptoms of recurrent DVT (leg pain, swelling, redness, warmth) and pulmonary embolism (shortness of breath, chest pain, rapid heart rate), with instructions to seek immediate medical attention if these develop. Additionally, the patient should be counseled on DVT prevention strategies including regular physical activity, adequate hydration, and avoiding prolonged immobility. If there are concerns about recurrence risk or if the patient has other comorbidities that might warrant continued anticoagulation, a hematology consultation could be considered for individualized recommendations. It's worth noting that the guidance from the SSC of the ISTH 1 is more focused on unprovoked PE or DVT, which does not directly apply to this patient's situation, and therefore, the recommendation from the Chest guideline 1 takes precedence.

Some key points to consider in this decision include:

• The patient's DVT was provoked, which generally has a better prognosis and lower risk of recurrence compared to unprovoked DVT.
• The patient has completed a standard course of anticoagulation therapy with apixaban.
• The negative Doppler ultrasound indicates that the clot has resolved.
• Elevated D-dimer levels can be seen in many conditions and are not specific to recurrent DVT, especially in older adults.
• The risk of anticoagulant-related bleeding must be weighed against the risk of recurrent DVT.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Profile

• 65-year-old patient with a history of provoked Deep Vein Thrombosis (DVT)
• On Eliquis (apixaban) for 6 months
• Negative Doppler ultrasound
• Elevated D-dimer levels

Treatment Considerations

• The decision to extend anticoagulation is based on the risk of recurrence and the risk of bleeding complications 2, 3, 4
• Patients with provoked DVT are generally at lower risk of recurrence compared to those with unprovoked DVT 3, 4
• Elevated D-dimer levels are associated with an increased risk of recurrence 2, 4, 5, 6

Management Options

• Continue anticoagulation with apixaban, considering the patient's elevated D-dimer levels and the potential benefits of extended treatment 5
• Monitor the patient's D-dimer levels and adjust treatment accordingly, although the use of D-dimer testing to guide treatment decisions is still a topic of debate 5, 6
• Consider the patient's individual risk factors, such as age and comorbidities, when making treatment decisions 3, 4, 6

Key Considerations

• The risk of recurrence and bleeding complications must be carefully weighed when making treatment decisions 2, 3, 4
• Regular follow-up and monitoring are essential to adjust treatment and minimize the risk of adverse events 2, 3, 4, 5, 6