What is the recommended dosing adjustment for Eliquis (apixaban) in a patient with a history of Deep Vein Thrombosis (DVT) initiating high-dose steroids?

Apixaban Dosing for Patients with History of DVT Starting High-Dose Steroids

For patients with a history of DVT who are initiating high-dose steroids, standard therapeutic dosing of apixaban (5 mg twice daily) should be maintained rather than reducing to prophylactic dosing, due to the increased thrombotic risk from steroids. 1

Rationale for Maintaining Therapeutic Dosing

High-dose corticosteroids significantly increase the risk of venous thromboembolism (VTE), which warrants maintaining full anticoagulation in patients with prior DVT:

• High-dose steroids (≥1-2 mg/kg/day of prednisone) are recognized as a persistent risk factor for thrombosis 1
• The American Society of Hematology (ASH) recommends extended-phase anticoagulation for VTE provoked by persistent risk factors 1
• Patients with VTE diagnosed in the absence of transient provocation or with persistent risk factors should receive extended-phase anticoagulation 1

Apixaban Dosing Considerations

Standard Therapeutic Dosing

• Maintain apixaban 5 mg twice daily during high-dose steroid therapy
• Do not reduce to the extended secondary prevention dose (2.5 mg twice daily) while on high-dose steroids 1

Dose Adjustments Only for Specific Scenarios

• Dose reduction to 2.5 mg twice daily is only appropriate for extended secondary prevention after completing at least 6 months of treatment AND when the persistent risk factor (high-dose steroids) is no longer present 1
• Renal function should be monitored during steroid therapy, as significant changes may warrant dose adjustment if CrCl falls below 30 mL/min 1

Clinical Decision Algorithm

1. Assess thrombotic risk:

   • High-dose steroids (≥1-2 mg/kg/day prednisone) = persistent risk factor 1
   • Prior history of DVT = increased baseline risk

2. Determine appropriate apixaban dosing:

   • During high-dose steroid therapy: Maintain 5 mg twice daily 1
   • After steroid taper (if extended anticoagulation needed): Consider reducing to 2.5 mg twice daily 1

3. Monitor for:

   • Signs/symptoms of recurrent VTE
   • Bleeding complications
   • Changes in renal function that might affect dosing

Important Considerations

• Drug interactions: Certain medications used with steroids (e.g., some antifungals) may interact with apixaban metabolism, requiring dose adjustment 2
• Duration of therapy: Continue therapeutic anticoagulation for the entire duration of high-dose steroid therapy plus at least 3 months after steroid discontinuation 1
• Renal function: Monitor closely as steroids may affect kidney function, which could impact apixaban clearance 1

Common Pitfalls to Avoid

• Pitfall #1: Reducing to prophylactic dosing (2.5 mg twice daily) during high-dose steroid therapy, which provides inadequate protection against recurrent VTE
• Pitfall #2: Failing to recognize that high-dose steroids represent a persistent risk factor requiring continued therapeutic anticoagulation
• Pitfall #3: Not monitoring for drug interactions between apixaban and other medications commonly used with steroids

By maintaining therapeutic apixaban dosing during high-dose steroid therapy, you provide optimal protection against recurrent VTE while managing the increased thrombotic risk associated with corticosteroid treatment.