What are the next steps for a patient with deep vein thrombosis (DVT) and unilateral leg swelling, status post (s/p) surgery, who has been placed on Eliquis (apixaban)?

Management of DVT in a Post-Surgical Patient on Apixaban

For a 58-year-old male with post-surgical DVT and unilateral leg swelling who has been started on Eliquis (apixaban), the next steps should include early ambulation, consideration of compression stockings, outpatient management if appropriate, and continued anticoagulation with apixaban for at least 3 months.

Immediate Management

• Early ambulation should be encouraged rather than bed rest, as this helps reduce symptoms and does not increase the risk of clot embolization 1
• Assess for adequacy of home circumstances to determine if outpatient management is appropriate (well-maintained living conditions, support from family/friends, phone access, ability to return to hospital if needed) 1
• If home circumstances are adequate and symptoms are not severe, outpatient treatment is recommended over hospitalization 1

Anticoagulation Management

• Continue apixaban therapy as prescribed - for acute DVT, the recommended dosing is 10 mg twice daily for the first 7 days, followed by 5 mg twice daily for the remainder of treatment 2
• Duration of anticoagulation should be at least 3 months for a surgery-provoked DVT 1
• No need for additional parenteral anticoagulation as apixaban can be used as monotherapy for DVT treatment 3
• Do not use an inferior vena cava (IVC) filter in addition to anticoagulation as this provides no additional benefit 1

Symptom Management

• Consider prescription of compression stockings to reduce the risk of post-thrombotic syndrome (PTS) 1
• If prescribed, compression stockings should be worn for 2 years, and potentially longer if PTS develops 1
• Elevate the affected limb when at rest to help reduce swelling 1

Monitoring and Follow-up

• Schedule follow-up within 2-4 weeks to assess treatment response, medication adherence, and bleeding complications
• Educate patient about signs of bleeding complications that would require medical attention
• No routine laboratory monitoring is required for apixaban, unlike warfarin therapy 1
• Assess for risk factors for recurrence to determine if extended therapy beyond 3 months might be beneficial 1

Special Considerations

• If the patient has cancer, consider switching to an oral Xa inhibitor (apixaban, edoxaban, rivaroxaban) which is now preferred over LMWH for cancer-associated thrombosis 1
• If the patient has severe renal impairment, dose adjustment may be necessary as apixaban is partially eliminated by the kidneys 2
• If the patient requires surgery during the treatment period, apixaban should be discontinued at least 48 hours prior to procedures with moderate/high bleeding risk, or 24 hours prior to procedures with low bleeding risk 2

Potential Complications to Monitor

• Bleeding complications - apixaban increases the risk of bleeding but has been shown to have a lower risk of major bleeding compared to conventional therapy 3
• Recurrent VTE - monitor for new or worsening symptoms of DVT or PE 4
• Post-thrombotic syndrome - can develop in up to 50% of patients with DVT despite adequate anticoagulation 1

Remember that this post-surgical DVT is considered a provoked event, so the recommended duration of therapy is 3 months rather than extended therapy 1.