How long should a patient be on Eliquis (apixaban) after a pulmonary embolism (PE) and would a cardiologist determine when to stop anticoagulation?

Duration of Anticoagulation with Eliquis After Pulmonary Embolism

For patients with pulmonary embolism (PE), anticoagulation with Eliquis (apixaban) should be continued for at least 3 months for provoked PE and indefinitely (with dose adjustment after 6 months) for unprovoked PE, with management typically coordinated between primary care physicians and specialists in hematology, pulmonology, or vascular medicine rather than cardiology alone. 1

Anticoagulation Duration Based on PE Classification

The duration of anticoagulation therapy depends primarily on whether the PE was provoked or unprovoked:

Provoked PE (with transient risk factors)

• 3 months of full-dose apixaban (5mg twice daily) for PE associated with major transient risk factors such as surgery or trauma 1
• After 3 months, anticoagulation can be discontinued if the risk factor has resolved 1, 2

Unprovoked PE

• Initial 6 months of full-dose apixaban (5mg twice daily) 1
• Then continue indefinitely with reduced-dose apixaban (2.5mg twice daily) 1
• This recommendation is based on the substantial risk of recurrence (>5% annually) after discontinuation of anticoagulation 1, 3

Special Situations

• Cancer-associated PE: At least 6 months, extended if cancer remains active 1
• Hormone-associated PE: 3 months if hormone therapy is discontinued, indefinite if continued 1
• Recurrent PE: Indefinite anticoagulation 1
• Antiphospholipid antibody syndrome: Indefinite with vitamin K antagonist 1

Specialist Management and Follow-up

While cardiology may be involved in the initial management of PE, especially if there are cardiac complications, the decision to discontinue anticoagulation typically involves:

• Pulmonologists - Often the primary specialists managing PE
• Hematologists - Particularly for complex cases or those with underlying coagulation disorders
• Vascular medicine specialists - For comprehensive thrombosis management
• Primary care physicians - For ongoing monitoring in coordination with specialists

Monitoring and Risk Assessment

For patients on indefinite anticoagulation:

• Regular assessment of bleeding risk factors 1
• Low-risk patients: Annual assessment
• High-risk patients: Assessment every 3-6 months 1

Important Considerations

• The decision to continue anticoagulation indefinitely after a first unprovoked proximal PE is strengthened if the patient is male 3
• D-dimer testing one month after stopping anticoagulant therapy may help identify patients at higher risk of recurrence 3
• Full-dose apixaban (5 mg twice daily) may be continued in patients with high recurrence risk and low bleeding risk 1

Common Pitfalls to Avoid

• Pitfall #1: Discontinuing anticoagulation too early for unprovoked PE

  • Patients with unprovoked PE have a high recurrence risk regardless of initial treatment duration 1, 4

• Pitfall #2: Failing to reassess bleeding risk regularly

  • Bleeding risk factors include advanced age (>75 years), previous bleeding, active cancer, previous stroke, renal/hepatic disease, and concomitant antiplatelet therapy 1

• Pitfall #3: Assuming cardiology should be the sole specialty managing anticoagulation decisions

  • A multidisciplinary approach involving pulmonology, hematology, or vascular medicine is often more appropriate for long-term management

The evidence strongly supports that the minimal duration of anticoagulation for PE is 3 months, with indefinite treatment recommended for unprovoked PE due to the high risk of recurrence 1, 4, 3.