What is the protocol for a patient with a history of Deep Vein Thrombosis (DVT) who wants to discontinue Eliquis (apixaban) and switch to once daily 81mg aspirin (acetylsalicylic acid)?

Protocol for Transitioning from Apixaban to Aspirin After DVT

For patients with a history of DVT who want to discontinue Eliquis (apixaban) and switch to once daily 81mg aspirin, the appropriate protocol is to complete the full recommended treatment course with apixaban before considering any transition, as aspirin is significantly less effective than anticoagulants for preventing recurrent VTE. 1

Assessment Before Transition

Before considering any transition from apixaban to aspirin, evaluate:

• Time since initial DVT diagnosis (duration of anticoagulation therapy)
• Whether the DVT was provoked (by surgery, trauma, immobilization) or unprovoked
• Risk factors for recurrence (male gender, PE vs DVT, positive D-dimer after stopping anticoagulation)
• Patient's bleeding risk profile
• Presence of active cancer or other prothrombotic conditions

Recommended Protocol

Step 1: Complete Appropriate Duration of Anticoagulation

• All patients with acute DVT should receive at least 3 months of anticoagulation therapy 1, 2
• For provoked DVT (by surgery, trauma, etc.): 3 months of anticoagulation is typically sufficient
• For unprovoked DVT: Consider extended anticoagulation, especially for:
  • Second unprovoked VTE
  • First unprovoked proximal DVT
  • DVT associated with active cancer
  • Male patients
  • Patients with positive D-dimer 1 month after stopping anticoagulation

Step 2: Transition Protocol

If the decision is made to discontinue apixaban after completing appropriate therapy:

1. Stop apixaban without tapering - no overlap is required 3
2. Begin aspirin 81mg daily the day after the last apixaban dose
3. No bridging therapy is needed between apixaban and aspirin

Step 3: Post-Transition Monitoring

• Monitor for signs/symptoms of recurrent VTE (leg swelling, pain, shortness of breath)
• Consider D-dimer testing 1 month after stopping anticoagulation to assess recurrence risk 2
• Reassess the decision periodically, especially if risk factors change

Important Considerations

• Efficacy gap: Aspirin is significantly less effective than anticoagulants for preventing recurrent VTE 4
• Reduced-dose option: For patients at high risk of recurrence but concerned about bleeding, reduced-dose apixaban (2.5mg twice daily) is more effective than aspirin while maintaining a favorable safety profile 5, 6
• Risk stratification: The decision to stop anticoagulation should be based on the patient's individual risk of recurrence versus bleeding risk 1, 2

Special Populations

• Cancer patients: Should remain on anticoagulation (preferably DOAC) rather than switching to aspirin as long as active cancer persists 1
• Multiple previous VTEs: Higher risk of recurrence even on low-dose DOACs; aspirin may be insufficient 5
• Recent VTE (< 3-6 months): Transition to aspirin is not recommended due to high recurrence risk 1, 2

Common Pitfalls to Avoid

• Transitioning to aspirin before completing the minimum recommended duration of anticoagulation (3 months)
• Assuming aspirin provides equivalent protection against recurrent VTE (it does not)
• Using doses of aspirin higher than 81-100mg daily (higher doses do not provide additional protection but increase bleeding risk) 4
• Failing to consider reduced-dose apixaban (2.5mg twice daily) as an alternative for extended therapy in high-risk patients 1, 6

Remember that the decision to transition from apixaban to aspirin represents a significant reduction in protection against recurrent VTE and should be made carefully after completing the appropriate duration of anticoagulation therapy.