What is an alternative to Eliquis (apixaban) for a patient with a history of unprovoked Pulmonary Embolism (PE) who cannot afford it?

Alternative Anticoagulants for Unprovoked Pulmonary Embolism in Patients Who Cannot Afford Eliquis (Apixaban)

For patients with unprovoked pulmonary embolism who cannot afford Eliquis (apixaban), rivaroxaban is the recommended alternative direct oral anticoagulant, or warfarin with a target INR of 2.0-3.0 if cost remains prohibitive. 1

First-Line Alternatives to Apixaban

Direct Oral Anticoagulants (DOACs)

• Rivaroxaban is a suitable alternative to apixaban for patients with unprovoked PE, offering similar efficacy with once-daily dosing 1, 2
• Rivaroxaban has the advantage of not requiring initial parenteral anticoagulation (unlike dabigatran and edoxaban), making it more convenient for patients 1, 3
• The initial dosing for rivaroxaban is 15 mg twice daily for 21 days followed by 20 mg once daily for extended treatment 1, 3
• Edoxaban is another alternative but requires initial parenteral anticoagulation for at least 5 days before transitioning 1, 3

Traditional Anticoagulants

• Warfarin (vitamin K antagonist) with a target INR of 2.0-3.0 remains an effective and less expensive alternative if DOACs are unaffordable 1
• Initial treatment with parenteral anticoagulation (LMWH, UFH, or fondaparinux) is required for at least 5 days when using warfarin, until the INR is 2.0-3.0 for two consecutive days 1
• Low molecular weight heparin (LMWH) can be considered, particularly in patients with active cancer 1

Duration of Treatment for Unprovoked PE

• For patients with a first unprovoked PE and low or moderate bleeding risk, extended anticoagulation therapy beyond 3 months is suggested 1
• For patients with a first unprovoked PE and high bleeding risk, 3 months of anticoagulation is recommended 1
• For patients with a second unprovoked VTE, extended anticoagulation therapy is strongly recommended for those with low bleeding risk 1
• Periodic reassessment of the risk-benefit ratio of continued anticoagulation is mandatory (e.g., annually) 1

Special Considerations

Renal Function

• Rivaroxaban and other DOACs should be avoided in patients with creatinine clearance <30 mL/min 1, 3
• For patients with severe renal impairment, warfarin may be the preferred option 1

Bleeding Risk Assessment

• Consider patient's age, comorbidities, concomitant medications, and history of bleeding when selecting an anticoagulant 1
• Patients with high bleeding risk may benefit from the shorter 3-month course of anticoagulation 1

Medication Adherence

• Consider the dosing frequency when selecting an alternative (rivaroxaban transitions to once-daily dosing after initial treatment) 3, 4
• Warfarin requires regular INR monitoring, which may be inconvenient but also ensures adherence through regular follow-up 1

Practical Approach to Selection

1. First choice: Rivaroxaban if affordable (no need for bridging therapy) 1, 2
2. Second choice: Edoxaban or dabigatran if parenteral bridging is acceptable 1, 3
3. Most affordable option: Warfarin with target INR 2.0-3.0 (requires bridging and monitoring) 1

Patient Assistance Programs

• Investigate manufacturer patient assistance programs for DOACs before switching to warfarin 2
• Consider generic warfarin with discount pharmacy programs if DOACs remain unaffordable 1

Monitoring Requirements

• Warfarin requires regular INR monitoring to maintain a target of 2.0-3.0 1
• DOACs do not require routine coagulation monitoring, which may offset some costs through fewer clinic visits 4
• All patients should be monitored for signs of bleeding or recurrent thrombosis regardless of anticoagulant choice 1