What to do when a patient with a deep vein thrombosis (DVT) or pulmonary embolism (PE) on apixaban (Eliquis) taper dosing requests a refill?

Management of Apixaban Refill for Patient with History of Blood Clot

For a patient who had a blood clot and was placed on apixaban taper dosing (10 mg twice daily for 7 days followed by 5 mg twice daily), the refill should be continued at the 5 mg twice daily maintenance dose for a minimum of 3 months total treatment duration, with consideration for extended therapy based on risk factors.

Appropriate Apixaban Dosing for DVT/PE Treatment

• The standard treatment regimen for DVT/PE with apixaban is 10 mg orally twice daily for the first 7 days (initial loading dose), followed by 5 mg orally twice daily for the remainder of the treatment period 1, 2
• This dosing regimen is considered a category 1 recommendation by the NCCN for the treatment of venous thromboembolism 1
• Apixaban is preferred over vitamin K antagonists (like warfarin) due to its fixed dosing regimen, no need for laboratory monitoring, and lower risk of major bleeding 1, 3

Duration of Therapy

• A minimum 3-month treatment phase of anticoagulation is recommended for all patients with acute VTE who don't have contraindications to anticoagulation 1
• For patients with a major transient risk factor (e.g., surgery), extended anticoagulation beyond 3 months is not recommended 1
• For patients with unprovoked VTE or VTE associated with persistent risk factors, extended-phase anticoagulation with a DOAC is recommended 1, 4
• For patients with active cancer, extended anticoagulation (no scheduled stop date) is recommended if bleeding risk is not high 1

Extended Treatment Considerations

• If extended treatment beyond the initial 3-6 months is indicated, the dose can be maintained at 5 mg twice daily or reduced to 2.5 mg twice daily for long-term prevention of recurrent DVT/PE 2, 5
• Extended treatment with apixaban 2.5 mg twice daily has been shown to reduce the risk of recurrent VTE without significantly increasing the risk of major bleeding 4
• For patients with provoked VTE who have enduring risk factors, extended treatment with low-dose apixaban (2.5 mg twice daily) resulted in significantly lower risk of recurrent VTE compared to placebo (1.3% vs 10.0%) 4

Assessment Before Refilling

• Evaluate for any signs or symptoms of recurrent thrombosis (e.g., swelling, pain, erythema in extremities, unexplained dyspnea) 1
• Assess for any bleeding complications since starting therapy 1, 2
• Review renal function, as dose adjustment may be needed for patients with severe renal impairment 5, 2
• Check for any new medications that might interact with apixaban, particularly combined P-glycoprotein and strong CYP3A4 inhibitors (e.g., ketoconazole, ritonavir), which would require dose reduction 2

Special Considerations

• For patients with cancer-associated thrombosis, apixaban is now preferred over low molecular weight heparin, with similar efficacy and no increased risk of major bleeding 1, 6
• If the patient needs any surgical or invasive procedures, apixaban should be discontinued at least 24-48 hours prior depending on the bleeding risk of the procedure 1
• Never abruptly discontinue apixaban without a plan for alternative anticoagulation, as this increases the risk of thrombotic events 2
• For patients with gastric or gastroesophageal lesions, apixaban may be safer than other DOACs, though LMWH is preferred in these cases 1

Common Pitfalls to Avoid

• Don't confuse the dosing for atrial fibrillation with VTE treatment dosing (AF starts at 5 mg twice daily, while VTE treatment starts at 10 mg twice daily for 7 days) 5, 2
• Don't discontinue therapy prematurely without assessing the patient's risk factors for recurrence 2, 4
• Don't forget to assess for drug interactions that might require dose adjustments 2
• Avoid missing doses - if a dose is missed, it should be taken as soon as possible on the same day and twice-daily administration should be resumed (the dose should not be doubled) 2