What are the next steps for a 67-year-old female patient with bilateral pulmonary embolism (PE) who was started on Eliquis (apixaban) 5mg twice daily 3 weeks ago?

Management of a 67-Year-Old Female with Bilateral Pulmonary Embolism on Apixaban Follow-up

For a 67-year-old female with bilateral PE on apixaban 5mg twice daily for 3 weeks, the next steps should include routine re-evaluation at 3-6 months after the acute PE event, assessment of risk factors for recurrence, and determination of optimal anticoagulation duration based on whether this was a provoked or unprovoked event. 1

Immediate Follow-up Assessment

• Evaluate clinical response to treatment, including resolution of symptoms such as dyspnea, chest pain, and any hemodynamic abnormalities 2
• Assess medication adherence and tolerance to apixaban, including any bleeding complications 1
• Review renal and hepatic function, as these can affect apixaban metabolism and dosing 1
• Confirm the patient is receiving the correct dosing regimen: 10mg twice daily for the first 7 days followed by 5mg twice daily (verify this transition occurred properly) 3, 4

Determination of Anticoagulation Duration

• Identify whether the PE was provoked by a major transient/reversible risk factor or unprovoked, as this is the key determinant of treatment duration 1
• For PE secondary to a major transient/reversible risk factor (e.g., surgery, trauma), discontinue anticoagulation after 3 months 1
• For unprovoked PE or PE associated with persistent risk factors, extended anticoagulation of indefinite duration should be considered 1
• For recurrent VTE not related to a major transient risk factor, indefinite oral anticoagulant treatment is recommended 1

Risk Assessment for Extended Anticoagulation

• Assess bleeding risk using validated tools to identify and treat modifiable bleeding risk factors 1
• High bleeding risk factors include: advanced age (>75 years), previous bleeding, anemia, active cancer, previous stroke, chronic renal/hepatic disease, concomitant antiplatelet therapy, and other serious comorbidities 1
• Balance the risk of recurrent VTE against bleeding risk when considering extended anticoagulation 5
• If extended anticoagulation is planned, consider the standard dose of apixaban (5mg twice daily) or reduced dose (2.5mg twice daily) after at least 6 months of treatment 6

Long-term Follow-up Plan

• Schedule routine re-evaluation at 3-6 months after the acute PE event 1
• For patients receiving extended anticoagulation, reassess drug tolerance, adherence, renal/hepatic function, and bleeding risk at regular intervals (e.g., every 3-6 months for high-risk patients, annually for low-risk patients) 1
• Consider referral to a pulmonary hypertension/CTEPH expert center for patients who remain symptomatic with mismatched perfusion defects beyond 3 months 1
• Implement an integrated model of care to ensure optimal transition from hospital to ambulatory care 1

Special Considerations and Pitfalls

• Avoid premature discontinuation of anticoagulation without proper risk assessment, as this increases thrombotic risk 3
• Remember that NOACs like apixaban should not be used in patients with severe renal impairment or antiphospholipid antibody syndrome 1
• Be aware that the risk of recurrent VTE is highest in the first year after discontinuation of anticoagulation, particularly in patients with unprovoked events 7
• For patients with cancer-associated PE, consider indefinite anticoagulation as they have a high risk of recurrence 1