What is the preferred treatment between apixaban (Apixaban) and enoxaparin (Enoxaparin) for acute Deep Vein Thrombosis (DVT)?

Apixaban vs. Enoxaparin for Acute DVT Treatment

Apixaban is preferred over enoxaparin for the treatment of acute deep vein thrombosis (DVT) in non-cancer patients due to its comparable efficacy, significantly lower bleeding risk, and greater convenience of oral administration. 1, 2

Efficacy Comparison

• Apixaban has been shown to be non-inferior to conventional therapy (enoxaparin followed by warfarin) for the treatment of acute venous thromboembolism (VTE) including DVT 1, 2
• In the AMPLIFY trial, the primary efficacy outcome of recurrent symptomatic VTE or VTE-related death occurred in 2.3% of patients in the apixaban group compared to 2.7% in the conventional therapy group (relative risk 0.84; 95% CI 0.60-1.18) 2, 3
• The AMPLIFY-J study in Japanese patients with acute PE/DVT showed similar efficacy between apixaban and UFH/warfarin with no recurrent VTE in the apixaban group 4

Safety Profile

• Major bleeding occurred significantly less frequently with apixaban (0.6%) compared to conventional therapy (1.8%) in the AMPLIFY trial (relative risk 0.31; 95% CI 0.17-0.55; p<0.001) 2, 3
• The composite outcome of major bleeding and clinically relevant non-major bleeding was also significantly lower with apixaban (4.3%) compared to conventional therapy (9.7%) (relative risk 0.44; 95% CI 0.36-0.55; p<0.001) 2, 3
• The AMPLIFY-J study confirmed this safety advantage, with lower rates of major/clinically relevant non-major bleeding in the apixaban group (7.5%) compared to UFH/warfarin (28.2%) 4

Dosing and Administration

• Apixaban is administered orally at a dose of 10 mg twice daily for 7 days, followed by 5 mg twice daily for at least 6 months 1, 2
• Enoxaparin requires subcutaneous injections (typically 1 mg/kg twice daily), which is less convenient for patients 2, 3
• The fixed-dose regimen of apixaban eliminates the need for routine coagulation monitoring and dose adjustments that are required with warfarin following enoxaparin 1, 2

Special Populations

Cancer Patients

• For patients with DVT and active cancer, low molecular weight heparin (LMWH) such as enoxaparin is still suggested over apixaban (Grade 2C) 1
• Limited data exists on apixaban use in cancer patients, with only 2.7% of patients in the AMPLIFY trial having active cancer 1, 3
• Ongoing trials like ADAM-VTE are specifically evaluating apixaban versus dalteparin (another LMWH) in cancer-associated VTE 5

Renal Impairment

• Apixaban should be used with caution in patients with severe renal impairment (CrCl <15 mL/min) as these patients were excluded from clinical trials 1, 2
• Approximately 27% of apixaban is eliminated renally, making dose adjustments less critical compared to other anticoagulants with higher renal clearance 1, 6

Guideline Recommendations

• The 2016 CHEST guidelines suggest using a direct oral anticoagulant (DOAC) such as apixaban in preference to vitamin K antagonist therapy for the initial and long-term treatment of VTE in patients without cancer 1
• This recommendation is based on less bleeding with DOACs and greater convenience for patients and healthcare providers 1
• The European Society of Cardiology (ESC) guidelines also support the use of DOACs like apixaban for the treatment of acute DVT 1

Clinical Considerations

• Apixaban does not require initial parenteral anticoagulation, unlike some other DOACs such as dabigatran and edoxaban 1
• The convenience of oral administration may improve patient adherence compared to injectable enoxaparin 1, 2
• Apixaban has been studied in upper extremity DVT with favorable safety and efficacy outcomes compared to LMWH/warfarin 7

Potential Limitations

• Limited data exists for apixaban use in certain populations such as patients >75 years old, those with extreme body weights, or severe renal dysfunction 8
• Cost considerations may impact treatment decisions, as apixaban may be more expensive than enoxaparin in some healthcare systems 1
• Reversal options for apixaban in case of emergency bleeding are evolving, with andexanet alfa now available but requiring further study 8