Timing of Apixaban (Eliquis) Initiation After Pulmonary Embolism
For patients with pulmonary embolism (PE), apixaban (Eliquis) should be started directly or after a 1-2 day administration of parenteral anticoagulation (unfractionated heparin, low molecular weight heparin, or fondaparinux), with an increased dose for the first 7 days. 1
Initial Management of PE
- Immediate anticoagulation should be initiated when PE is suspected or confirmed, as this reduces mortality and morbidity 1
- For patients with PE who are eligible for a NOAC (non-vitamin K antagonist oral anticoagulant), a NOAC such as apixaban is preferred over vitamin K antagonists 1
- Parenteral anticoagulation with LMWH or fondaparinux is preferred over UFH for initial treatment in most cases, except in patients with severe renal impairment or those being considered for thrombolysis 1
Apixaban Dosing Schedule After PE
- Apixaban should be administered at 10 mg twice daily for the first 7 days 1, 2
- After the initial 7-day period, the dose should be reduced to 5 mg twice daily for the remainder of the treatment period 1, 2
- This regimen has been shown to be non-inferior to conventional therapy with significantly fewer bleeding events 3, 2
Transition from Parenteral to Oral Anticoagulation
- Apixaban can be started directly or after a 1-2 day administration of parenteral anticoagulation (UFH, LMWH, or fondaparinux) 1
- Unlike vitamin K antagonists (which require 5-7 days of overlapping parenteral therapy), apixaban can be initiated with minimal or no parenteral bridging 1
- The higher initial dose of apixaban (10 mg twice daily) for the first 7 days is designed to achieve rapid therapeutic anticoagulation 1
Duration of Treatment
- All patients with PE should receive therapeutic anticoagulation for at least 3 months 1
- For patients with first PE secondary to a major transient/reversible risk factor, anticoagulation can be discontinued after 3 months 1, 4
- For patients with recurrent VTE not related to a major transient risk factor, indefinite oral anticoagulant treatment is recommended 1
- Regular reassessment of drug tolerance, adherence, renal/hepatic function, and bleeding risk is necessary for patients on extended anticoagulation 1
Special Considerations
- Apixaban should not be used in patients with severe renal impairment or those with antiphospholipid antibody syndrome 1
- Apixaban should not be used during pregnancy or lactation 1
- In real-world studies, apixaban has shown lower risks of major bleeding, clinically relevant non-major bleeding, and recurrent VTE compared to warfarin 3
Common Pitfalls to Avoid
- Delaying anticoagulation when PE is suspected in patients with intermediate to high clinical probability 1
- Failing to use the correct initial higher dose of apixaban (10 mg twice daily for 7 days) 1
- Unnecessarily prolonging parenteral anticoagulation before transitioning to apixaban 1
- Not considering patient-specific factors such as renal function, weight, and drug interactions when selecting anticoagulation 1