What is the role of Eliquis (apixaban) in the treatment of Deep Vein Thrombosis (DVT)?

Apixaban (Eliquis) for Deep Vein Thrombosis Treatment

Apixaban is a highly effective first-line treatment option for DVT that is preferred over warfarin due to superior safety and comparable efficacy. 1

Dosing Regimen for Acute DVT Treatment

For acute DVT treatment, initiate apixaban at 10 mg orally twice daily for the first 7 days, then reduce to 5 mg twice daily for the remainder of therapy. 2, 3

• This regimen eliminates the need for initial parenteral anticoagulation (unlike warfarin or some other DOACs), simplifying treatment initiation 3, 4
• No laboratory monitoring or dose adjustments based on INR are required 1
• The medication can be started immediately upon diagnosis without bridging therapy 3

Evidence Supporting Apixaban Over Warfarin

Major clinical guidelines from the American Society of Hematology (2020) and CHEST (2016) suggest using DOACs including apixaban over vitamin K antagonists for DVT treatment in patients without cancer. 1

Key Benefits:

• Reduced major bleeding risk by 37% compared to warfarin/LMWH (RR 0.63; 95% CI 0.47-0.84), representing 6 fewer major bleeding events per 1000 patients treated 1
• Equivalent efficacy for preventing recurrent VTE and mortality 1
• Lower burden on patients due to absence of dietary restrictions, INR monitoring, and frequent dose adjustments 1
• Real-world data shows 27-39% reduction in major bleeding and 25-39% reduction in recurrent VTE compared to warfarin 5

Treatment Duration

For provoked DVT (associated with surgery or transient risk factors), treat for 3 months then discontinue anticoagulation. 1, 6

For unprovoked DVT, consider extended therapy beyond 3 months with no scheduled stop date. 1

• After completing at least 6 months of treatment for DVT, the dose for extended therapy to reduce recurrence risk is 2.5 mg twice daily (reduced from the acute treatment dose) 3, 2
• Extended anticoagulation is recommended for unprovoked VTE but strongly recommended against for provoked VTE due to low recurrence risk and ongoing bleeding risk 6

Important Contraindications and Cautions

Avoid apixaban in patients with:

• Severe renal impairment (CrCl <15 mL/min) - this is an absolute contraindication 2, 3
• Severe hepatic impairment 2
• Antiphospholipid syndrome - use LMWH instead 1, 2

Use with caution in:

• Moderate renal dysfunction (CrCl 15-29 mL/min), as 27% of the drug undergoes renal elimination 2
• Patients with creatinine clearance 25-30 mL/min were excluded from major trials 1

Special Population: Cancer-Associated DVT

For cancer-associated DVT, LMWH is preferred over apixaban as first-line therapy (Grade 2C recommendation), though apixaban remains an acceptable alternative 1

• Recent evidence shows apixaban has similar or lower rates of recurrent VTE compared to dalteparin in cancer patients 2
• The preference for LMWH is based on older evidence; newer data suggests apixaban may be reasonable in selected cancer patients 1

Perioperative Management

Discontinue apixaban at least 48 hours before elective surgery with moderate-to-high bleeding risk, or at least 24 hours before procedures with low bleeding risk. 3

• Bridging anticoagulation during the 24-48 hour interruption is not generally required 3
• Resume apixaban once adequate hemostasis is established post-procedure 3

Common Pitfalls to Avoid

• Do not double the dose if a dose is missed - take the missed dose as soon as remembered on the same day, then resume the regular twice-daily schedule 3
• Do not use initial INR measurements when transitioning from apixaban to warfarin - apixaban affects INR, making early measurements unreliable for warfarin dosing 3
• Do not continue extended anticoagulation for provoked DVT - this exposes patients to unnecessary bleeding risk without meaningful VTE reduction benefit 6