What is the indication for Eliquis (apixaban) and aspirin in the management of pulmonary embolism?

Indications for Eliquis (Apixaban) and Aspirin in Pulmonary Embolism Management

Eliquis (apixaban) is indicated for the treatment of pulmonary embolism (PE) and for reducing the risk of recurrent PE following initial therapy, while aspirin may be considered only for extended VTE prophylaxis in patients who refuse or cannot tolerate oral anticoagulants. 1, 2

Eliquis (Apixaban) Indications

Acute Treatment of PE

• Apixaban is FDA-approved for the treatment of pulmonary embolism 1
• The recommended dosing regimen for acute PE treatment is 10 mg taken orally twice daily for the first 7 days, followed by 5 mg taken orally twice daily 1
• When initiating oral anticoagulation in a patient with PE who is eligible for a NOAC (including apixaban), a NOAC is recommended in preference to a vitamin K antagonist (Class I, Level A recommendation) 2

Prevention of Recurrent PE

• Apixaban is indicated to reduce the risk of recurrent PE following initial therapy 1
• For extended anticoagulation after completing 6 months of therapeutic anticoagulation, a reduced dose of apixaban (2.5 mg twice daily) should be considered (Class IIa, Level A recommendation) 2
• Extended oral anticoagulation of indefinite duration should be considered for patients with:
  • A first episode of PE with no identifiable risk factor 2
  • A first episode of PE associated with a persistent risk factor 2
  • A first episode of PE associated with a minor transient/reversible risk factor 2

Benefits of Apixaban

• Apixaban has been shown to be non-inferior to conventional therapy (enoxaparin/warfarin) in preventing recurrent VTE 2, 3
• Apixaban significantly reduces major bleeding compared to conventional therapy 2
• Apixaban reduces all-cause hospitalizations compared to enoxaparin/warfarin and shortens length of hospital stay in patients with acute VTE 3

Aspirin Indications in PE Management

Limited Role in PE Management

• Aspirin is not a first-line therapy for PE treatment or standard prophylaxis 2
• Aspirin may be considered only for extended VTE prophylaxis in patients who refuse to take or are unable to tolerate any form of oral anticoagulants (Class IIb, Level B recommendation) 2

Evidence for Aspirin

• Aspirin has been associated with a 30-35% reduction in the risk of VTE recurrence compared with placebo when used after termination of standard oral anticoagulation 2
• However, more recent trials have demonstrated the superiority of anticoagulation with rivaroxaban (either 20 mg or 10 mg once daily) over aspirin for secondary prophylaxis of VTE recurrence 2

Clinical Decision-Making Algorithm

1. Initial PE Treatment:

   • Start with apixaban 10 mg twice daily for 7 days, then 5 mg twice daily 1
   • Continue treatment for at least 3 months (Class I, Level A recommendation) 2

2. Duration of Anticoagulation (decision points after initial 3 months):

   • For first PE with major transient/reversible risk factor: discontinue anticoagulation after 3 months (Class I, Level B) 2
   • For recurrent VTE not related to major transient risk factor: indefinite anticoagulation (Class I, Level B) 2
   • For first unprovoked PE: consider extended anticoagulation of indefinite duration (Class IIa, Level A) 2
   • For PE with persistent risk factor: consider extended anticoagulation (Class IIa, Level C) 2

3. Extended Anticoagulation Options:

   • If extended anticoagulation is chosen: use reduced dose apixaban (2.5 mg twice daily) after 6 months of therapeutic anticoagulation (Class IIa, Level A) 2
   • If patient refuses or cannot tolerate oral anticoagulants: consider aspirin for extended prophylaxis (Class IIb, Level B) 2

4. Monitoring Requirements:

   • For patients on extended anticoagulation: regularly reassess drug tolerance, adherence, hepatic and renal function, and bleeding risk (Class I, Level C) 2

Important Considerations and Caveats

• Apixaban should not be used in patients with severe renal impairment, during pregnancy and lactation, or in patients with antiphospholipid antibody syndrome 2
• For patients with antiphospholipid antibody syndrome, indefinite treatment with a vitamin K antagonist is recommended instead of a NOAC 2
• For patients with cancer-associated PE, low molecular weight heparin, edoxaban, or rivaroxaban are preferred over apixaban, though the choice should be individualized 2
• Aspirin is significantly less effective than anticoagulants for preventing recurrent VTE and should only be used when anticoagulants cannot be used 2