Management of DVT in a Patient with History of PE Taking Eliquis (Apixaban)
For a female patient with history of PE who is currently taking Eliquis (apixaban) and presents with a new DVT, the most appropriate approach is to increase the apixaban dose to 10 mg twice daily for 7 days, followed by resumption of the standard 5 mg twice daily dosing.
Initial Management
Assessment and Immediate Actions
- Confirm DVT diagnosis through appropriate imaging (typically ultrasound)
- Assess hemodynamic stability and rule out concurrent PE
- Evaluate for any contraindications to continued anticoagulation
Anticoagulation Strategy
Dose Adjustment for Current Apixaban Therapy:
Rationale for Continuing Apixaban:
- Apixaban has demonstrated non-inferiority to conventional therapy (LMWH/warfarin) for DVT treatment 2, 3
- Continuing the same agent (apixaban) but at treatment doses simplifies care and avoids switching between anticoagulants 4
- The American College of Physicians and American Academy of Family Physicians recommend DOACs over vitamin K antagonists for DVT treatment 4
Outpatient Management
Eligibility for Outpatient Care
The patient can likely be managed as an outpatient if:
- Hemodynamically stable
- No signs of massive DVT or PE
- No significant comorbidities requiring hospitalization
- Adequate social support and ability to adhere to treatment
The British Thoracic Society guidelines support outpatient management of DVT with DOACs, noting that "patients with confirmed PE being treated in the outpatient setting should be offered treatment with either LMWH and dabigatran, LMWH and edoxaban or a single-drug regimen (apixaban or rivaroxaban)" 4.
Monitoring Requirements
- Follow-up visit within 1-2 weeks to assess treatment response and compliance
- Monitor for signs of bleeding complications
- No routine coagulation monitoring is required with apixaban 1
Additional Interventions
Compression Therapy
- Prescribe compression stockings to prevent post-thrombotic syndrome
- Begin within 1 month of diagnosis and continue for at least 1 year 4
- 30-40 mmHg graduated compression stockings are typically recommended
Activity Recommendations
- Encourage ambulation as tolerated
- Avoid prolonged immobility
- Elevate affected limb when at rest
Long-term Management Considerations
Duration of Treatment
- For patients with recurrent VTE (as in this case with history of PE and new DVT), extended anticoagulation (indefinite duration) is typically recommended 4, 5
- The CHEST guidelines recommend extended therapy (no scheduled stop date) for recurrent VTE 4
Follow-up Evaluation
- Reassess at 3-6 months after acute DVT 5
- Evaluate for signs of post-thrombotic syndrome
- Assess drug tolerance, adherence, and bleeding risk
Important Cautions and Considerations
Bleeding Risk Assessment
- Monitor for signs of bleeding, particularly in high-risk patients
- No specific bleeding risk assessment is required beyond standard clinical evaluation for patients on DOACs 4
Potential Pitfalls to Avoid
- Do not discontinue apixaban abruptly as this increases thrombotic risk 1
- Do not add parenteral anticoagulants (LMWH/UFH) when already on therapeutic apixaban
- Do not delay dose adjustment to treatment levels for the new DVT
- Avoid concomitant use of medications that are combined P-gp and strong CYP3A4 inhibitors, as they may increase bleeding risk 1
Special Circumstances
- If severe renal impairment (CrCl <30 ml/min): Consider dose adjustment or alternative anticoagulation 5
- If active cancer: LMWH may be preferred over DOACs, though evidence is evolving 4
By following this approach, you provide effective treatment for the new DVT while maintaining continuity of care with the patient's existing anticoagulant regimen.