How many months do you treat a pulmonary embolism (PE) with Eliquis (apixaban)?

Duration of Apixaban Treatment for Pulmonary Embolism

The duration of apixaban (Eliquis) treatment for pulmonary embolism depends on whether the PE was provoked or unprovoked, with 3 months being recommended for provoked PE and indefinite treatment (at least 6 months initial full dose followed by reduced dose) for unprovoked PE.

Treatment Duration Based on PE Classification

Provoked PE

• For PE provoked by surgery or other major transient risk factors: Treatment with apixaban for 3 months is recommended 1
• After 3 months, anticoagulation should be discontinued if the risk factor has resolved 1
• This includes patients with PE provoked by:
  • Surgery
  • Trauma
  • Other temporary immobilization

Unprovoked PE

• For first unprovoked PE with low/moderate bleeding risk: Initial 6 months of full-dose apixaban (5mg twice daily) followed by indefinite treatment with reduced-dose apixaban (2.5mg twice daily) 1, 2
• For first unprovoked PE with high bleeding risk: 3 months of anticoagulation is recommended 1
• For second unprovoked PE with low bleeding risk: Indefinite anticoagulation is strongly recommended 1

Cancer-Associated PE

• For PE in patients with active cancer: At least 6 months of anticoagulation, with extended treatment if cancer remains active 1, 2
• In patients with low or moderate bleeding risk: Extended anticoagulant therapy is recommended 1
• In patients with high bleeding risk: Extended therapy should still be considered 1

Risk Assessment for Extended Treatment

When considering extended anticoagulation beyond the initial treatment period:

1. Assess recurrence risk factors:

   • Unprovoked PE (highest risk)
   • Male sex
   • Positive D-dimer after stopping anticoagulation
   • Residual venous thrombosis
   • Previous VTE episode

2. Assess bleeding risk factors:

   • Advanced age (>75 years)
   • Previous bleeding
   • Active cancer
   • Previous stroke
   • Chronic renal/hepatic disease
   • Concomitant antiplatelet therapy

3. Monitoring during extended therapy:

   • Regular reassessment of the risk-benefit ratio (at least annually) 1
   • Monitoring of renal and hepatic function
   • Assessment of drug adherence and tolerance

Dosing Considerations

• Initial treatment: Apixaban 10mg twice daily for 7 days 3
• Maintenance treatment: Apixaban 5mg twice daily 3
• Extended treatment: Consider reduced dose of 2.5mg twice daily for long-term therapy beyond 6 months 2, 3

Clinical Considerations and Pitfalls

• Do not discontinue anticoagulation prematurely in unprovoked PE patients, as they have a substantial risk for recurrence (>5% annually) after discontinuation, regardless of treatment duration 2, 4

• Avoid routine use of IVC filters in patients who can receive anticoagulation 1

• Consider the improved safety profile of apixaban compared to warfarin when making decisions about extended therapy - real-world data shows lower risks of both major bleeding (by 27-39%) and recurrent VTE (by 25-39%) with apixaban versus warfarin 5

• Remember that recurrences often present as PE (not just DVT), with potentially fatal outcomes 4 - this should factor into decisions about extended therapy

• Recognize that the risk of recurrent VTE persists for years after the initial event, particularly for unprovoked PE 6, 4

In summary, the duration of apixaban treatment for PE should be tailored based on whether the event was provoked or unprovoked, with consideration of individual bleeding risk factors. For most patients with unprovoked PE, extended or indefinite anticoagulation provides the best protection against recurrence with an acceptable safety profile.