Can Eliquis (apixaban) be continued indefinitely for Deep Vein Thrombosis (DVT) prophylaxis?

Indefinite Use of Eliquis (Apixaban) for DVT Prophylaxis

Yes, Eliquis (apixaban) can be continued indefinitely for DVT prophylaxis in appropriate patients, particularly those with unprovoked VTE or persistent risk factors. 1

Duration of Anticoagulation: Decision Framework

The decision to continue Eliquis indefinitely depends on several key factors:

Risk Stratification for Extended Therapy

1. High risk for recurrence (indefinite anticoagulation recommended):

   • Unprovoked VTE (no identifiable risk factor)
   • Persistent risk factors (e.g., active cancer)
   • Second episode of unprovoked VTE
   • First unprovoked proximal DVT or PE with low bleeding risk

2. Moderate risk (case-by-case decision):

   • First unprovoked VTE with moderate bleeding risk
   • Chronic risk factors with some expected improvement

3. Low risk (3-month therapy usually sufficient):

   • VTE provoked by transient/reversible risk factor (e.g., surgery)
   • First unprovoked isolated distal (calf) DVT

Dosing for Extended Prophylaxis

For extended prophylaxis (beyond initial 3-6 months), the American Society of Hematology (ASH) suggests:

• Reduced-dose apixaban (2.5 mg twice daily) is preferred over full-dose (5 mg twice daily) 1, 2
• This reduced dose maintains efficacy while potentially reducing bleeding risk

Evidence Supporting Indefinite Use

The 2021 CHEST guideline strongly recommends offering extended-phase anticoagulation with a DOAC for patients with unprovoked VTE or VTE provoked by persistent risk factors 1. This recommendation is based on:

1. Recurrence risk: Without extended anticoagulation, unprovoked VTE has a recurrence rate exceeding 5% annually 3

2. Efficacy of extended therapy: Studies show reduced-dose apixaban (2.5 mg twice daily) effectively prevents recurrent VTE during extended treatment periods 2, 4

3. Safety profile: A 2022 study with 30-month follow-up of cancer patients on reduced-dose apixaban showed low rates of major bleeding (3.1%) 4

Monitoring Recommendations for Indefinite Therapy

For patients on indefinite apixaban:

• Reassess the risk-benefit balance at least annually 1
• Evaluate at times of significant health status changes
• Monitor for signs of bleeding complications
• No routine coagulation monitoring is required (unlike warfarin)

Important Considerations and Caveats

• Patient preference should be considered alongside clinical factors
• Bleeding risk must be continuously assessed and may change over time
• Drug interactions should be evaluated with any new medications
• Renal function should be monitored as apixaban is partially eliminated by the kidneys (27% renal clearance) 5
• Cost and adherence may impact long-term therapy success

Special Populations

• Cancer patients: Extended anticoagulation is particularly beneficial, with studies showing safety of reduced-dose apixaban after initial 6 months of full-dose treatment 4
• Elderly patients: Use caution and consider dose reduction (2.5 mg twice daily) if age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 5
• Renal impairment: Apixaban should be avoided in severe renal impairment (CrCl <15 mL/min) 5

Conclusion

For DVT prophylaxis, apixaban can be continued indefinitely in patients with unprovoked VTE or persistent risk factors, with periodic reassessment of risks and benefits. The reduced dose of 2.5 mg twice daily is appropriate for most patients on extended therapy.