What is the recommended treatment for a patient with a second unprovoked Deep Vein Thrombosis (DVT) using Eliquis (apixaban)?

Treatment of Second Unprovoked DVT with Apixaban (Eliquis)

For patients with a second unprovoked DVT, extended anticoagulation therapy with apixaban is strongly recommended, with reduced-dose apixaban 2.5 mg twice daily being the preferred long-term regimen after initial treatment. 1, 2

Initial Treatment Phase

For the initial treatment of DVT:

1. First 7 days: Apixaban 10 mg twice daily orally 3
2. Days 8-180: Apixaban 5 mg twice daily orally 3

Extended Treatment Phase (Beyond 6 Months)

After completing the initial 6 months of therapy:

• Switch to reduced-dose regimen: Apixaban 2.5 mg twice daily for indefinite (extended) treatment 1, 3
• This reduced-dose regimen maintains efficacy while minimizing bleeding risk compared to full-dose therapy 1

Rationale for Extended Therapy

The recommendation for extended therapy is based on:

• High recurrence risk: Patients with a second unprovoked DVT have approximately 12% annual risk of recurrence if anticoagulation is stopped 2
• Strong evidence: The American College of Chest Physicians (ACCP) provides a strong recommendation (Grade 1B) for extended anticoagulation in patients with a second unprovoked VTE who have low bleeding risk 1, 2
• Mortality benefit: Extended anticoagulation reduces the risk of recurrent VTE by up to 71% compared to discontinuation after 3 months 2

Bleeding Risk Considerations

Treatment duration should be adjusted based on bleeding risk:

• Low bleeding risk: Extended (indefinite) anticoagulation strongly recommended 1, 2
• Moderate bleeding risk: Extended anticoagulation suggested (weaker recommendation) 1, 2
• High bleeding risk: Consider limiting treatment to 3 months and reassessing 1

Monitoring and Follow-up

• Regular reassessment: All patients on extended therapy should have treatment reassessed at least annually 1
• Renal function: Monitor renal function as apixaban should be avoided in patients with severe renal impairment (CrCl <15 mL/min) 1, 3
• Drug interactions: Reduce apixaban dose by 50% when used with combined P-gp and strong CYP3A4 inhibitors 3

Advantages of Apixaban for Extended Therapy

• Fixed dosing: No need for routine anticoagulation monitoring 4, 5
• Lower bleeding risk: Significantly lower risk of major bleeding compared to warfarin 3, 6
• Long-term safety: Recent studies with >2 years of follow-up show low rates of recurrent VTE (3.7%) and major bleeding (0.3%) with reduced-dose apixaban 7

Common Pitfalls to Avoid

• Premature discontinuation: Stopping therapy increases thrombotic risk; if discontinuation is necessary for procedures, follow appropriate interruption protocols 3
• Failure to transition to reduced dose: After 6 months, patients should be switched from treatment dose (5 mg BID) to prevention dose (2.5 mg BID) for extended therapy 1, 3
• Inadequate patient education: Patients need to understand the indefinite nature of therapy and importance of adherence
• Missing periodic reassessment: Bleeding risk may change over time and requires periodic reassessment 1

Remember that while extended therapy is generally recommended for second unprovoked DVT, the decision should be reassessed periodically, especially if the patient's bleeding risk changes over time.