What is the recommended duration of anticoagulation therapy with Eliquis (apixaban) for a patient with a deep vein thrombosis (DVT) in the lower extremity?

Duration of Apixaban (Eliquis) Therapy for Lower Extremity DVT

For most patients with lower extremity DVT, anticoagulation with apixaban should be continued for at least 3 months, with extended therapy (no scheduled stop date) recommended for unprovoked DVT or DVT associated with persistent risk factors. 1

Treatment Duration Based on DVT Type

Provoked DVT

• DVT provoked by surgery: 3 months of anticoagulation recommended 1
• DVT provoked by non-surgical transient risk factor: 3 months of anticoagulation recommended 1
• Isolated distal DVT with transient risk factor: 3 months of anticoagulation recommended 1

Unprovoked DVT

• Unprovoked proximal DVT: Extended-phase anticoagulation (no scheduled stop date) recommended 1
• Unprovoked isolated distal DVT: At least 3 months of anticoagulation, with consideration for extended therapy 1

Dosing Regimen for Apixaban

1. Initial treatment phase (first 7 days): 10 mg twice daily 2
2. Maintenance phase (after 7 days through 6 months): 5 mg twice daily 2
3. Extended phase (beyond 6 months): 2.5 mg twice daily 1, 2, 3

Evidence Quality and Recommendations

The American College of Chest Physicians (ACCP) guidelines provide strong recommendations (Grade 1B) for 3 months of anticoagulation for provoked DVT 1. For unprovoked DVT, the 2021 CHEST guideline update strongly recommends extended-phase anticoagulation with a direct oral anticoagulant (DOAC) like apixaban 1.

The AMPLIFY trial demonstrated that apixaban was noninferior to conventional therapy (enoxaparin/warfarin) for VTE treatment with significantly less bleeding 1, 4. The AMPLIFY-EXT trial showed that extended treatment with apixaban (both at treatment and reduced doses) significantly reduced recurrent VTE compared to placebo 3, 4.

Special Considerations

• Reduced dose for extended therapy: For patients receiving extended therapy beyond 6 months, the reduced dose of apixaban (2.5 mg twice daily) is suggested over full-dose therapy 1, 3
• Cancer-associated thrombosis: In patients with DVT and cancer, low-molecular-weight heparin was traditionally preferred, but recent guidelines suggest oral factor Xa inhibitors like apixaban may be appropriate for many cancer patients 5
• Renal impairment: Apixaban should be avoided in patients with severe renal impairment (CrCl <15 mL/min) 1
• Annual reassessment: Patients on extended anticoagulation should have their therapy reassessed at least annually 1

Common Pitfalls to Avoid

1. Premature discontinuation: Stopping anticoagulation too early increases thrombotic risk 2
2. Failure to transition to reduced dose: Not switching to 2.5 mg twice daily for extended therapy beyond 6 months 1
3. Missing the reassessment: Failing to periodically reevaluate the need for continued anticoagulation in patients on extended therapy 1
4. Inappropriate use in contraindicated populations: Using apixaban in patients with severe renal dysfunction, antiphospholipid syndrome, or pregnancy 1, 5

The decision for extended therapy should be based on weighing the risk of recurrent VTE against bleeding risk, with strong evidence supporting extended therapy with reduced-dose apixaban for unprovoked DVT to prevent recurrence while minimizing bleeding risk 1, 3.