How to manage a patient with non-occlusive deep vein thrombosis (DVT) on the femoral vein, severe anemia (Hemoglobin (Hgb) 7.7), and currently on Aspirin (ASA) and Eliquis (Apixaban) 5mg?

Management of Non-Occlusive Femoral DVT with Severe Anemia (Hgb 7.7) on Dual Therapy

Immediately discontinue aspirin and continue Eliquis (apixaban) 5mg twice daily while addressing the severe anemia urgently. The combination of anticoagulation and antiplatelet therapy significantly increases major bleeding risk, and with hemoglobin of 7.7 g/dL, the bleeding risk outweighs any cardiovascular benefit from aspirin in this acute setting 1.

Immediate Actions

Stop Aspirin Now

• The combination of aspirin and apixaban dramatically increases bleeding risk, particularly in the setting of severe anemia 1
• Critically reassess whether there is an absolute indication for aspirin (recent acute coronary syndrome within 12 months or recent coronary stent) 1
• If no compelling cardiovascular indication exists, aspirin should remain discontinued 1

Continue Apixaban for DVT Treatment

• Maintain apixaban 5mg twice daily as this is the appropriate dose after the initial 7-day loading period (10mg twice daily) for DVT treatment 2
• Apixaban is preferred over warfarin for DVT treatment and does not require bridging with parenteral anticoagulation 3, 2
• The femoral vein location qualifies as proximal DVT requiring full anticoagulation regardless of whether it is occlusive or non-occlusive 3

Address the Severe Anemia Urgently

• Hemoglobin of 7.7 g/dL represents severe anemia and significantly increases mortality and major bleeding risk in VTE patients 4
• Investigate the cause immediately: gastrointestinal bleeding (especially given dual therapy exposure), occult malignancy, nutritional deficiency, or chronic disease 4
• Consider transfusion based on symptoms, hemodynamic stability, and ongoing bleeding risk 4
• Patients with anemia and VTE have 1.84 times higher risk of all-cause mortality and 2.83 times higher risk of major bleeding compared to non-anemic VTE patients 4

Anticoagulation Management Strategy

If Aspirin Must Be Continued (Rare Scenarios)

• Only continue aspirin if there is a recent acute coronary event or coronary intervention requiring dual antiplatelet therapy 1
• In this case, apixaban remains the preferred anticoagulant as it has been better studied in combination with antiplatelet therapy compared to other DOACs 1
• Monitor extremely closely for bleeding complications, particularly gastrointestinal and intracranial bleeding 1
• Consider reducing apixaban dose to 2.5mg twice daily only if patient meets dose reduction criteria: age ≥80 years AND (body weight ≤60 kg OR serum creatinine ≥1.5 mg/dL) 2

Standard DVT Treatment Duration

• Continue therapeutic anticoagulation for minimum 3 months for the acute DVT treatment phase 3, 1
• After 3 months, reassess for extended anticoagulation based on whether DVT was provoked or unprovoked 3, 1
• For unprovoked DVT, consider indefinite anticoagulation with apixaban 2.5mg twice daily after completing initial 6 months of treatment 2

Monitoring and Follow-Up

Short-Term (First 2 Weeks)

• Repeat complete blood count within 48-72 hours to ensure hemoglobin is stable or improving 4
• Assess for signs of active bleeding: melena, hematochezia, hematemesis, hematuria, or expanding hematomas
• Monitor for worsening DVT symptoms that might indicate thrombus extension 3

Ongoing Surveillance

• Repeat ultrasound in 1 week if symptoms worsen to assess for proximal extension, though this is less critical since the femoral vein is already proximal 3
• Continue monitoring hemoglobin weekly until stable and cause of anemia is identified and treated 4
• Reassess cardiovascular indication for aspirin with cardiology consultation if initially deemed necessary 1

Special Considerations for Non-Occlusive DVT

Anticoagulation Is Still Mandatory

• Non-occlusive DVT in the femoral vein still requires full therapeutic anticoagulation to prevent extension and pulmonary embolism 3
• The femoral vein is a proximal location with significant risk for PE if left untreated 3
• Do not consider surveillance-only approach, which is reserved for isolated distal (calf) DVT in select cases 3

No Role for Thrombolysis

• Catheter-directed thrombolysis is NOT indicated for non-occlusive femoral DVT with mild-moderate symptoms 3
• Thrombolysis should be reserved for limb-threatening DVT (phlegmasia cerulea dolens) or highly symptomatic iliofemoral DVT in young patients with low bleeding risk 3
• Given the severe anemia (Hgb 7.7), this patient has extremely high bleeding risk, making thrombolysis absolutely contraindicated 3

Critical Pitfalls to Avoid

• Do not continue dual therapy (aspirin + apixaban) without compelling cardiovascular indication - the bleeding risk with Hgb 7.7 is prohibitive 1, 4
• Do not reduce apixaban dose below therapeutic levels unless specific dose reduction criteria are met (age ≥80 AND weight ≤60kg OR creatinine ≥1.5) 2
• Do not delay anemia workup - severe anemia in VTE patients dramatically worsens outcomes and may indicate occult bleeding or malignancy 4
• Do not treat non-occlusive femoral DVT with surveillance alone - this is proximal DVT requiring full anticoagulation 3
• Do not use inferior vena cava filter unless absolute contraindication to anticoagulation exists, which is not the case here 3