What to do for a patient with calf pain, on Eliquis (apixaban) for a history of Deep Vein Thrombosis (DVT), who had to hold anticoagulation for 4 days due to surgery?

Management of Patient with Calf Pain on Apixaban After Holding for Surgery

For a patient with calf pain who was on Eliquis (apixaban) for history of DVT but had to hold it for 4 days for surgery, you should immediately resume apixaban at the full therapeutic dose (5 mg twice daily) as the risk of recurrent DVT is high in this scenario.

Assessment of Current Situation

Risk Factors for Recurrent DVT:

• Recent surgery (within past week) - major risk factor for VTE
• History of previous DVT - indicates higher baseline risk
• Interruption of anticoagulation for 4 days
• Current calf pain - concerning for potential recurrent DVT

Management Algorithm

1. Immediate Anticoagulation Resumption:

   • Resume apixaban at full therapeutic dose (5 mg twice daily) immediately 1
   • Do not use a stepwise approach with lower doses first, as the patient already has concerning symptoms

2. Diagnostic Evaluation:

   • Arrange urgent compression ultrasound of the affected leg to confirm or rule out DVT
   • If ultrasound is negative but clinical suspicion remains high, consider repeat ultrasound in 5-7 days

3. Anticoagulation Duration:

   • If new DVT is confirmed: Treat for at least 3 months 2
   • If no new DVT is found: Continue previous anticoagulation plan based on original DVT history
   • For unprovoked DVT with low/moderate bleeding risk: Consider extended anticoagulation 2

Special Considerations

Timing of Anticoagulation Resumption:

• The American College of Chest Physicians guidelines recommend resuming anticoagulation as soon as adequate hemostasis has been established 2
• For high bleeding risk surgeries, guidelines typically suggest waiting 48-72 hours, but with symptoms of possible DVT, the risk-benefit ratio favors immediate resumption 2

Monitoring:

• Assess for signs of bleeding at surgical site
• Monitor for worsening or resolution of calf pain
• Evaluate for other signs of DVT progression (increased swelling, warmth, erythema)

Common Pitfalls to Avoid

1. Delaying anticoagulation resumption: With symptoms suggestive of DVT, delaying anticoagulation increases risk of thrombus extension and pulmonary embolism.

2. Using prophylactic dosing: For patients with history of DVT and current symptoms, therapeutic dosing is required, not prophylactic dosing.

3. Failing to obtain imaging: Clinical assessment alone is insufficient to rule out DVT, especially in high-risk patients.

4. Overlooking bleeding risk: While resuming anticoagulation is important, ensure surgical site hemostasis is adequate.

The management approach prioritizes prevention of potentially fatal thromboembolism while maintaining vigilance for bleeding complications. Immediate resumption of therapeutic anticoagulation is warranted given the concerning symptoms and risk factors in this patient.