What is the best course of action for a patient with a positive Deep Vein Thrombosis (DVT) while on Eliquis (apixaban) 5mg twice daily?

Management of DVT in a Patient Already on Apixaban 5mg BID

For a patient who develops a DVT while on therapeutic apixaban 5mg twice daily, the recommended approach is to increase the dose to 10mg twice daily for 7 days, followed by resumption of the 5mg twice daily dose, while evaluating for potential causes of anticoagulation failure. 1, 2

Initial Management

• For patients with acute DVT who develop a new clot while on therapeutic anticoagulation, the first step is to verify medication adherence and assess for potential drug interactions or underlying conditions that might reduce anticoagulant effectiveness 1
• According to the FDA label for apixaban, the recommended dose for acute DVT treatment is 10mg twice daily for the first 7 days, followed by 5mg twice daily 2
• When a patient develops a DVT while already on therapeutic apixaban, temporarily increasing to the higher initial treatment dose (10mg twice daily) for 7 days is appropriate to achieve more intensive anticoagulation 2, 3

Evaluation for Anticoagulation Failure

• Assess medication adherence - confirm the patient has been taking apixaban as prescribed without missed doses 1, 4
• Evaluate for drug interactions - particularly combined P-glycoprotein (P-gp) and strong CYP3A4 inducers that may reduce apixaban efficacy 2
• Consider underlying conditions that might contribute to hypercoagulability:
  • Active cancer (may require switching to LMWH or higher intensity anticoagulation) 5, 1
  • Antiphospholipid syndrome or other thrombophilias 6
  • Anatomical factors that might impair venous return 1

Treatment Setting

• For most patients with DVT while on anticoagulation, outpatient management is appropriate if home circumstances are adequate 5, 1
• Home treatment is conditional on well-maintained living conditions, strong support from family or friends, phone access, and ability to quickly return to hospital if deterioration occurs 5
• Early ambulation is suggested over initial bed rest 1

Duration of Therapy

• For patients who develop DVT while on anticoagulation, extended anticoagulation therapy (no scheduled stop date) is recommended 5
• Annual reassessment of the risk-benefit ratio of continued anticoagulation is recommended 5
• For patients with unprovoked VTE or VTE provoked by persistent risk factors, extended-phase anticoagulation with a DOAC is recommended 5, 1

Special Considerations

• If the patient has cancer, consider switching to a parenteral agent (LMWH) if the DVT occurred despite appropriate DOAC therapy 5, 1
• For patients with recurrent VTE despite therapeutic anticoagulation, consider:
  • Increasing the intensity of anticoagulation 3
  • Switching to a different class of anticoagulant 1
  • Adding an inferior vena cava (IVC) filter only if anticoagulation is contraindicated 5

Common Pitfalls and Caveats

• Failure to assess medication adherence is a common pitfall when evaluating anticoagulation failure 4
• Avoid automatically assuming treatment failure without investigating potential causes of breakthrough thrombosis 1, 4
• Do not discontinue anticoagulation without transitioning to an alternative agent, as this significantly increases thrombotic risk 2
• Remember that apixaban may need dose adjustment when used with combined P-gp and strong CYP3A4 inhibitors 2
• Avoid using aspirin alone for secondary prevention as it is much less effective than anticoagulants for preventing recurrent VTE 5