What is the recommended management for a patient with atrial fibrillation (a fib) on Eliquis (apixaban) 5 mg twice daily who develops a new deep vein thrombosis (DVT) in the left leg?

From the Guidelines

For a patient on Eliquis (apixaban) 5 mg twice daily for atrial fibrillation who develops a new deep vein thrombosis (DVT) in the left leg, the recommended management is to continue the current dose of Eliquis 5 mg twice daily, as the current anticoagulant is already effective for both atrial fibrillation and DVT, and changing the dose or anticoagulant is not recommended unless there are specific concerns about the patient's condition or adherence to the medication regimen 1.

Key Considerations

• The patient is already on an effective anticoagulant for atrial fibrillation, which also covers the treatment of DVT, as suggested by the guidelines for antithrombotic therapy for VTE disease 1.
• The guidelines suggest that in patients with DVT of the leg or PE and no cancer, dabigatran, rivaroxaban, apixaban, or edoxaban can be used as long-term anticoagulant therapy, with a preference over VKA therapy 1.
• There is no recommendation to change the choice of anticoagulant after the first 3 months of treatment for DVT or PE, suggesting that the current medication can be continued for extended therapy 1.

Management Approach

• Continue Eliquis (apixaban) 5 mg twice daily, as it is already providing adequate anticoagulation for both conditions.
• Evaluate potential causes for the breakthrough thrombotic event, including medication adherence issues, drug interactions, or underlying conditions.
• Provide patient education on signs of pulmonary embolism, the importance of elevating the affected leg, and maintaining mobility as tolerated.
• Schedule regular follow-up appointments to monitor the resolution of the DVT and reassess the long-term anticoagulation strategy.

From the FDA Drug Label

The recommended dose of apixaban tablets for the treatment of DVT and PE 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.

For a patient with atrial fibrillation on Eliquis (apixaban) 5 mg twice daily who develops a new DVT, the recommended management would be to increase the dose to 10 mg twice daily for the first 7 days, and then decrease to 5 mg twice daily after 7 days, as per the treatment guidelines for DVT. 2

Key points:

• Increase apixaban dose to 10 mg twice daily for the first 7 days
• Decrease apixaban dose to 5 mg twice daily after 7 days
• Monitor patient for signs of bleeding or other adverse effects

From the Research

Management of Atrial Fibrillation with Apixaban

• The patient is currently on Eliquis (apixaban) 5 mg twice daily for atrial fibrillation and develops a new deep vein thrombosis (DVT) in the left leg.
• According to the study 3, apixaban is used to treat venous thromboembolism (VTE) at 10 mg twice daily for 7 days, followed by 5 mg twice daily.
• However, the patient is already on 5 mg twice daily, so the management approach may need to be adjusted.
• The study 3 suggests that coagulation markers may differ in patients with VTE prescribed higher doses of apixaban, and a dose adjustment may be warranted.

Considerations for Dose Adjustment

• The study 4 recommends the use of dabigatran 150 mg twice daily for patients with atrial fibrillation who have a high risk of embolism, but this is not directly applicable to the patient's current situation.
• The study 5 compares the effectiveness and safety of apixaban with other direct oral anticoagulants (DOACs) and finds that apixaban is associated with a lower risk of gastrointestinal bleeding.
• The study 6 demonstrates the safety and effectiveness of continuous apixaban in patients undergoing atrial fibrillation ablation, but this is not directly relevant to the patient's current situation.
• The study 7 confirms the effectiveness and safety of apixaban therapy in daily-care patients with atrial fibrillation, but does not provide specific guidance on managing DVT in this population.

Next Steps

• Consider consulting with a healthcare professional to determine the best course of action for managing the patient's DVT while on apixaban therapy 3, 5.
• The healthcare professional may need to weigh the risks and benefits of adjusting the patient's apixaban dose or adding additional therapies to manage the DVT 3, 7.