DVT While on Eliquis and Plavix: Treatment Changes
Switch from apixaban (Eliquis) to low-molecular-weight heparin (LMWH) for this breakthrough DVT, as this represents anticoagulation failure on a non-LMWH agent. 1
Immediate Management Approach
Change anticoagulation to LMWH when a patient develops recurrent or breakthrough VTE while on a direct oral anticoagulant (DOAC) like apixaban. The American College of Chest Physicians specifically recommends switching to LMWH for recurrent VTE occurring on non-LMWH anticoagulants. 1
Key Management Steps:
Discontinue apixaban immediately and initiate therapeutic-dose LMWH (such as enoxaparin 1 mg/kg subcutaneously twice daily or 1.5 mg/kg once daily). 1
Continue Plavix (clopidogrel) only if there is a compelling cardiovascular indication (such as recent coronary stent), but recognize this significantly increases bleeding risk when combined with therapeutic anticoagulation. 1
Investigate potential causes of anticoagulation failure, including medication non-adherence, drug interactions, malabsorption, or underlying malignancy (particularly occult cancer). 2
Duration and Monitoring
Treat with LMWH for at least 3 months as the initial treatment phase for this acute DVT. 1
Reassess at 3 months to determine if extended anticoagulation (no scheduled stop date) is warranted based on whether this represents unprovoked VTE or if there are persistent risk factors. 1
If recurrent VTE occurs even on LMWH, increase the LMWH dose by approximately 25-33% rather than switching to another agent. 1
Special Considerations
If Cancer is Discovered:
Continue LMWH indefinitely as it is superior to other anticoagulants in cancer-associated thrombosis. 1
LMWH is preferred over DOACs, vitamin K antagonists, and other agents for cancer-associated VTE. 1
Bleeding Risk with Dual Therapy:
The combination of therapeutic anticoagulation plus Plavix carries substantial bleeding risk. Carefully weigh whether the antiplatelet agent can be discontinued or if the cardiovascular indication truly requires continuation. 1
If Plavix must be continued for recent acute coronary syndrome or stent placement, accept the elevated bleeding risk but counsel the patient extensively and monitor closely. 1
Critical Pitfalls to Avoid
Do not simply increase the apixaban dose – breakthrough VTE on a DOAC is a treatment failure requiring a class switch to LMWH. 1
Do not place an IVC filter unless there is an absolute contraindication to anticoagulation, which is not the case here. 1
Do not assume patient adherence – verify the patient has been taking apixaban correctly (2.5 mg or 5 mg twice daily as prescribed) before attributing this to true pharmacologic failure. 2
Do not overlook malignancy – breakthrough VTE on adequate anticoagulation should prompt consideration of occult cancer screening, particularly in patients without other clear provoking factors. 1