What are the risks of not starting Eliquis (apixaban) treatment for Deep Vein Thrombosis (DVT) in the legs?

Risks and Benefits of Not Starting Eliquis Treatment for DVT in Legs

Not treating DVT in the legs with anticoagulation like Eliquis (apixaban) carries a 50-60% risk of pulmonary embolism with an associated mortality rate of 25-30% if left untreated. 1

Critical Risks of Withholding Anticoagulation

Immediate Life-Threatening Complications

• Pulmonary embolism occurs in 50-60% of untreated DVT patients, representing the most serious immediate risk 1
• Mortality from untreated DVT-related PE ranges from 25-30% 1
• The risk is particularly high when DVT extends above the knee (proximal DVT), which is strongly associated with PE 1

Location-Specific Risk Stratification

• Above-the-knee (proximal) DVT: Strongly associated with increased PE risk and requires immediate anticoagulation 1
• Below-the-knee (distal) DVT: Lower immediate PE risk, but one-sixth of patients experience proximal extension 1
• If anticoagulation is not initiated for distal DVT, serial imaging at 1 week is mandatory to exclude proximal extension 1

Long-Term Complications Without Treatment

Recurrent VTE Risk:

• For unprovoked DVT without treatment after initial 3-month therapy: 10% recurrence by 1 year and up to 30% by 5-10 years 1
• Even for provoked DVT, discontinuing anticoagulation prematurely increases recurrence risk 1

Post-Thrombotic Syndrome:

• Chronic leg pain, swelling, and skin changes develop in patients with inadequately treated DVT 1
• This significantly impacts quality of life and is preventable with appropriate anticoagulation 1

Benefits of Starting Eliquis (Apixaban)

Superior Efficacy Profile

• Apixaban is noninferior to conventional enoxaparin/warfarin therapy for treating DVT 1, 2
• Reduces recurrent VTE risk by 25-39% compared to warfarin in real-world studies 2
• In extended therapy, apixaban reduces recurrent VTE by 87% (hazard ratio 0.13) compared to placebo 3

Enhanced Safety Compared to Traditional Anticoagulation

• 37% reduction in major bleeding compared to warfarin/LMWH (6 fewer major bleeding events per 1000 patients) 4
• 27-39% lower risk of major bleeding in real-world comparative studies 2
• Clinically relevant non-major bleeding reduced by 17-28% versus warfarin 2

Practical Advantages

• No laboratory monitoring required (no INR checks) 4
• No dietary restrictions 4
• Fixed dosing regimen: 10 mg twice daily for 7 days, then 5 mg twice daily 1, 4
• No parenteral bridge therapy needed (unlike warfarin) 1

Treatment Duration Algorithm

For Provoked DVT (surgery, trauma, immobility):

• Standard recommendation: 3 months of anticoagulation, then discontinue 5, 4
• Extended therapy beyond 3 months is strongly recommended against for major transient risk factors 5
• The low recurrence risk does not justify bleeding risk from extended therapy 5

For Unprovoked DVT:

• Indefinite anticoagulation is recommended (strong recommendation) 1
• Risk of recurrence is 10% at 1 year and 30% by 5-10 years without continued therapy 1
• Annual reassessment is mandatory to review bleeding complications and continued indication 1

For Recurrent Unprovoked DVT:

• Indefinite anticoagulation is strongly recommended 1
• Recurrence risk reaches 12 per 100 patient-years without continued therapy 1

Critical Contraindications to Consider

Before withholding Eliquis, verify these are NOT present:

• Severe renal impairment (apixaban contraindicated) 4
• Antiphospholipid syndrome (use LMWH instead) 4
• Active cancer (LMWH preferred as first-line, though apixaban acceptable) 1, 4

Common Pitfalls to Avoid

Do not:

• Withhold anticoagulation for proximal DVT—the PE risk is unacceptably high 1
• Continue extended anticoagulation for provoked DVT beyond 3 months—this exposes patients to unnecessary bleeding risk 5, 4
• Assume below-the-knee DVT is benign without serial imaging if not anticoagulating 1
• Use clinical prediction scores alone without imaging to exclude DVT 1

Risk-Benefit Balance

The decision to withhold Eliquis should only occur in specific circumstances:

• Isolated below-the-knee DVT with ability to perform serial imaging at 1 week 1
• Absolute contraindications to anticoagulation (active bleeding, severe bleeding risk)
• Patient has completed appropriate treatment duration for provoked DVT (3 months) 5, 4

In all other scenarios, the mortality and morbidity risks of untreated DVT far outweigh the bleeding risks of apixaban, particularly given its superior safety profile compared to traditional anticoagulation 1, 4, 2.