Apixaban 2.5mg for Extended VTE Treatment
For extended treatment of venous thromboembolism (VTE), apixaban 2.5mg twice daily is the recommended regimen after completing at least 6 months of initial anticoagulation therapy.
Extended VTE Treatment with Apixaban
Dosing Regimen
- The recommended dose for extended treatment (beyond the initial treatment period) of VTE is apixaban 2.5mg taken orally twice daily 1
- Extended treatment should be initiated after completing at least 6 months of initial anticoagulation therapy for DVT or PE 1, 2
- The initial treatment phase typically consists of apixaban 10mg twice daily for 7 days followed by 5mg twice daily for the remainder of the initial treatment period (typically 3-6 months) 3, 1
Efficacy and Safety of Reduced-Dose Apixaban
- The American College of Chest Physicians suggests using reduced-dose apixaban (2.5mg twice daily) over full-dose apixaban (5mg twice daily) for extended-phase anticoagulation 2
- Reduced-dose apixaban (2.5mg twice daily) has been shown to significantly reduce the risk of recurrent VTE compared to placebo without substantially increasing the risk of major bleeding 4
- Extended treatment with apixaban 2.5mg twice daily is associated with an 86% reduction in VTE recurrence risk compared to placebo and a 73% reduction compared to aspirin 4
- Apixaban 2.5mg twice daily has a more favorable safety profile with lower bleeding risk compared to other anticoagulant therapies used for extended VTE treatment 4
Duration of Extended Treatment
- Extended-phase anticoagulation does not have a predefined stop date 2
- The decision to continue extended therapy should be reevaluated at least annually and at times of significant changes in health status 2, 3
- Studies of extended-phase anticoagulation typically monitored patients for durations of about 2 to 4 years 2
- Recent real-world evidence shows mean extended-treatment duration with apixaban up to 10 months with continued effectiveness and safety 5
Patient Selection for Extended Treatment
Recommended for Extended Treatment
- Patients with unprovoked VTE (occurring in the absence of a transient risk factor) 2
- Patients with VTE provoked by persistent risk factors 2
- Patients at high risk of VTE recurrence 3
Not Recommended for Extended Treatment
- Patients with VTE provoked by a major transient risk factor (e.g., surgery) 2
- Patients with VTE provoked by a minor transient risk factor 2
- Patients with high bleeding risk 2
Monitoring and Follow-up
- Regular assessment for signs of recurrent VTE or bleeding complications 3
- Annual reassessment of the risk-benefit balance of continuing extended anticoagulation 2, 3
- Monitoring of renal function, as apixaban should be used with caution in patients with severe renal impairment (CrCl <15 mL/min) 3
Special Considerations
- For patients with cancer-associated thrombosis requiring extended treatment, low molecular weight heparin (LMWH) is traditionally suggested over apixaban, though recent evidence suggests apixaban may be effective and safe in this population as well 2, 6
- Recent studies show extended treatment with apixaban in cancer patients was associated with lower rates of recurrent VTE, major bleeding, and clinically relevant non-major bleeding compared to LMWH 6
- For patients who cannot receive a direct oral anticoagulant (DOAC), vitamin K antagonists (VKAs) may be used for extended treatment 2
- If a patient has decided to stop anticoagulants completely, aspirin may provide some protection against recurrent VTE but is much less effective than anticoagulants 2
Potential Pitfalls and Caveats
- Do not confuse the dosing regimen for initial treatment (10mg BID for 7 days, then 5mg BID) with the regimen for extended treatment (2.5mg BID) 1
- Extended treatment should only be initiated after completing at least 6 months of initial anticoagulation therapy 1
- Premature discontinuation of apixaban increases the risk of thrombotic events 1
- Patients with multiple previous VTE episodes may have a higher risk of recurrence even on low-dose DOAC therapy and may require closer monitoring 7