What is the appropriate treatment for pulmonary embolism with Eliquis (apixaban) in an elderly patient with mildly impaired renal function?

Treatment of Pulmonary Embolism with Apixaban in an Elderly Patient with Mild Renal Impairment

For an 88-year-old female weighing 110lbs with a creatinine clearance of 75 mL/min who has pulmonary embolism, the recommended treatment is apixaban 10 mg twice daily for the first 7 days followed by 5 mg twice daily for at least 3 months.

Initial Assessment and Treatment

• Apixaban is FDA-approved for the treatment of pulmonary embolism (PE) and is an appropriate choice for this patient 1
• The standard dosing regimen for PE treatment with apixaban is 10 mg twice daily for the first 7 days, followed by 5 mg twice daily 1
• No dose adjustment is required for this patient based on her creatinine clearance of 75 mL/min, as dose adjustments are only necessary for patients with severe renal impairment (CrCl <30 mL/min) 2
• The patient's age alone (88 years) does not necessitate dose adjustment for PE treatment 1
• The patient's weight (110 lbs/50 kg) does not require dose adjustment for PE treatment 1

Advantages of Apixaban in This Patient

• Non-vitamin K antagonist oral anticoagulants (NOACs) like apixaban are recommended over vitamin K antagonists (VKAs) when treating PE in patients eligible for NOACs 2
• Apixaban offers the advantage of fixed dosing without the need for routine laboratory monitoring 2
• Compared to traditional anticoagulation with vitamin K antagonists, apixaban has been associated with lower bleeding risk while maintaining efficacy 3
• Apixaban can be initiated immediately without the need for bridging with parenteral anticoagulants, simplifying treatment 2, 1

Duration of Treatment

• The minimum recommended duration of anticoagulation for PE is 3 months 2
• After the initial treatment period, the decision for extended therapy should be based on:
  • Risk of recurrence if anticoagulation is discontinued
  • Bleeding risk with continued therapy
  • Patient preference 2
• If extended anticoagulation beyond 6 months is decided, the dose can be reduced to 2.5 mg twice daily 2, 1

Monitoring and Follow-up

• Routine clinical evaluation is recommended 3-6 months after acute PE 2
• Regular assessment of renal function is important, especially in elderly patients, as significant deterioration would require reconsideration of dosing 2
• Monitor for signs of bleeding, which is the most common adverse effect of anticoagulation therapy 1
• Assess for symptoms of recurrent VTE during follow-up visits 2

Special Considerations for Elderly Patients

• Although age alone does not require dose adjustment for PE treatment with apixaban, elderly patients may have higher bleeding risk and should be monitored carefully 2
• Apixaban should be temporarily discontinued at least 48 hours prior to elective surgery or invasive procedures with moderate to high bleeding risk 1
• If a dose is missed, it should be taken as soon as possible on the same day and twice-daily administration should be resumed; the dose should not be doubled to make up for a missed dose 1

Potential Pitfalls and Cautions

• Avoid premature discontinuation of anticoagulation as it increases the risk of thrombotic events 1
• Avoid concomitant use with combined P-glycoprotein and strong CYP3A4 inhibitors, which would require dose adjustment 1
• Do not use apixaban in patients with severe renal impairment (CrCl <30 mL/min) or severe liver impairment 2
• Avoid use in patients with antiphospholipid antibody syndrome, where vitamin K antagonists are preferred 2