From the Guidelines
Stopping Eliquis (apixaban) after a pulmonary embolism (PE) requires careful consideration of individual risk factors and should be done under the guidance of a healthcare provider to minimize the risk of recurrent blood clots and bleeding complications. The decision to wean off Eliquis depends on several factors, including whether the PE was provoked by a temporary risk factor or unprovoked, the patient's bleeding risk, and their overall health status 1. Typically, treatment with Eliquis lasts at least 3-6 months, but may continue indefinitely for some patients. Eliquis is usually taken at a dose of 5mg twice daily, though some patients may receive 2.5mg twice daily based on age, weight, or kidney function.
Key Considerations
- The patient's bleeding risk should be assessed to identify and treat modifiable bleeding risk factors, which may influence decision-making on the duration and regimen/dose of anticoagulant treatment 1.
- For patients with a first PE/VTE secondary to a major transient/reversible risk factor, discontinuation of therapeutic oral anticoagulation is recommended after 3 months 1.
- Extended oral anticoagulation of indefinite duration should be considered for patients with a first episode of PE and no identifiable risk factor, or those with a persistent risk factor other than antiphospholipid antibody syndrome 1.
- If extended oral anticoagulation is decided after PE in a patient without cancer, a reduced dose of the NOACs apixaban (2.5 mg b.i.d.) or rivaroxaban (10 mg o.d.) should be considered after 6 months of therapeutic anticoagulation 1.
Recommendations
- Before stopping Eliquis, patients should have a thorough discussion with their healthcare provider about their individual risk factors for recurrent clots versus bleeding risks.
- Patients who receive extended anticoagulation should have their drug tolerance and adherence, hepatic and renal function, and bleeding risk reassessed at regular intervals 1.
- The ASH guideline panel provides a conditional recommendation that the standard dose or the lower dose of rivaroxaban or apixaban may be used for the secondary prevention of VTE, but additional research is necessary to identify which subsets of patients can safely use a lower-dose DOAC 2.
From the FDA Drug Label
If anticoagulation with apixaban is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant [see Dosage and Administration (2.4), Warnings and Precautions (5.1), and Clinical Studies (14. 1)]. The recommended dose of apixaban tablets for the treatment of PE is 10 mg taken orally twice daily for the first 7 days of therapy. After 7 days, the recommended dose is 5 mg taken orally twice daily. Reduction in the Risk of Recurrence of DVT and PE The recommended dose of apixaban tablets is 2. 5 mg taken orally twice daily after at least 6 months of treatment for DVT or PE [see Clinical Studies (14.3)].
The instructions for weaning off Eliquis (apixaban) after a pulmonary embolism (PE) are not explicitly stated in the drug label. However, the label does provide information on discontinuation of apixaban and consideration of coverage with another anticoagulant.
- To discontinue apixaban, consider the following:
- Completion of a course of therapy: The recommended duration of treatment for PE is not explicitly stated, but the label recommends treatment for at least 6 months.
- Coverage with another anticoagulant: If anticoagulation with apixaban is discontinued, consider coverage with another anticoagulant.
- Dosing for the treatment of PE:
- Initial dose: 10 mg taken orally twice daily for the first 7 days of therapy.
- Maintenance dose: 5 mg taken orally twice daily after 7 days.
- Reduction in the risk of recurrence: 2.5 mg taken orally twice daily after at least 6 months of treatment for DVT or PE. It is essential to consult with a healthcare professional for personalized guidance on weaning off Eliquis (apixaban) after a pulmonary embolism (PE) 3.
From the Research
Weaning Off Eliquis (Apixaban) After a Pulmonary Embolism (PE)
- The decision to wean off Eliquis (apixaban) after a pulmonary embolism (PE) should be made on a case-by-case basis, considering the individual patient's risk of recurrent VTE and bleeding 4, 5.
- There is no standard protocol for weaning off apixaban, but the treatment duration and dosing strategy can be guided by the patient's clinical presentation and risk factors 5, 6.
- For patients with provoked PE, a short-term course of anticoagulation (3 months) may be sufficient, while unprovoked events or those with continuing risk factors may require extended anticoagulation 5.
- The dosing strategy for apixaban can be either a treatment dose (5 mg twice daily) or a thromboprophylactic dose (2.5 mg twice daily), with the latter reducing the risk of recurrent VTE without increasing the rate of major bleeding 6.
- When transitioning from parenteral anticoagulation to apixaban, the recommended initial higher dose lead-in regimen may not be necessary, and a reduced lead-in duration may be considered in certain patients 7.
- Reduced-dose direct oral anticoagulants (DOACs), including apixaban, may be effective and safe in certain patients, with comparable efficacy and safety profiles to standard-dose therapy in the long-term treatment of acute pulmonary embolism 8.
Dosing Considerations
- The standard dose of apixaban for the treatment of VTE is 5 mg twice daily 6.
- A reduced dose of 2.5 mg twice daily may be considered for extended anticoagulation or in patients with certain risk factors 6.
- The dosing strategy should be individualized based on the patient's clinical presentation, risk factors, and renal function 5, 6.