What is the recommended dosing for long-term use of Eliquis (apixaban) for Deep Vein Thrombosis (DVT) prophylaxis?

Long-Term Apixaban for DVT Prophylaxis

For long-term DVT prophylaxis after completing initial treatment (≥6 months), apixaban 2.5 mg orally twice daily is the recommended dose for extended secondary prevention. 1, 2, 3

Initial Treatment Phase

Before transitioning to long-term prophylaxis, patients must complete the acute treatment phase:

• First 7 days: Apixaban 10 mg orally twice daily 1, 4, 3
• Days 8 through at least 3-6 months: Apixaban 5 mg orally twice daily 1, 4, 3

Extended/Long-Term Prophylaxis Dosing

After completing at least 6 months of initial anticoagulation therapy:

• Reduced-intensity dose: Apixaban 2.5 mg orally twice daily 1, 2, 3
• Alternative full-dose option: Apixaban 5 mg orally twice daily may be continued if higher thrombotic risk persists 1

The 2.5 mg twice daily dose provides effective secondary prevention with lower bleeding risk compared to continuing full therapeutic dosing. 5

Duration of Extended Therapy

The duration depends on DVT classification and risk factors:

• Provoked DVT (surgery, trauma, transient risk factor): Minimum 3 months total treatment, then reassess 2
• Unprovoked DVT: At least 3 months initial treatment, followed by extended therapy consideration based on bleeding risk 2
• Recurrent VTE or persistent risk factors: Indefinite anticoagulation with periodic reassessment (e.g., annually) 2

Recent evidence demonstrates that even patients with provoked DVT who have enduring risk factors benefit significantly from extended low-dose apixaban (2.5 mg twice daily), with 1.3% recurrence rate versus 10% with placebo over 12 months. 5

Clinical Decision Algorithm

Step 1: Classify the DVT

• Provoked by transient factor (surgery, trauma, immobility) vs. unprovoked 2
• Presence of enduring risk factors (active cancer, thrombophilia, obesity, immobility) 5

Step 2: Assess bleeding risk

• Low-moderate bleeding risk → proceed with extended therapy 2
• High bleeding risk → carefully weigh risks versus benefits; may still consider reduced-dose therapy 2

Step 3: Evaluate vein recanalization

• Persistent venous occlusion may warrant continued anticoagulation 6

Step 4: Select dosing strategy after 6 months

• Standard approach: Reduce to apixaban 2.5 mg twice daily 1, 2, 3
• Higher risk scenarios: Continue 5 mg twice daily 1

Special Populations

Cancer-associated DVT:

• DOACs including apixaban are preferred over warfarin 1
• Avoid apixaban in patients with gastric or gastroesophageal malignancies due to increased bleeding risk 1
• Consider LMWH (dalteparin or enoxaparin) as alternative in GI malignancies 1

Renal impairment:

• Contraindicated if creatinine clearance <15 mL/min 2
• Dose adjustment may be needed for CrCl 15-29 mL/min (consult FDA labeling) 3

Hepatic impairment:

• Avoid in significant hepatic impairment 2

Efficacy and Safety Data

Extended low-dose apixaban demonstrates:

• Recurrence reduction: 87% relative risk reduction versus placebo (HR 0.13) 5
• Major bleeding: Extremely low rate (0.3-0.4%) 7, 5
• Clinically relevant non-major bleeding: 2.5-4.8% 7, 5

These rates compare favorably to full-dose anticoagulation while maintaining efficacy. 8, 7

Key Advantages Over Traditional Therapy

• No need for INR monitoring 8
• No initial parenteral anticoagulation required 4, 8
• Fixed dosing without laboratory adjustment 8
• Lower bleeding risk with reduced-dose regimen 8, 5

Critical Monitoring Points

• Reassess need for continued anticoagulation at periodic intervals (annually recommended) 2
• Monitor for signs of recurrent VTE or bleeding complications 3
• Evaluate hemoglobin, hematocrit, and platelet count periodically 1
• Do not double dose if a dose is missed; take as soon as remembered on same day and resume regular schedule 3

Common Pitfalls to Avoid

• Premature discontinuation increases thrombotic risk significantly; if stopping apixaban, consider bridging with alternative anticoagulation 3
• Failing to reduce dose after 6 months in appropriate candidates misses opportunity to decrease bleeding risk 1, 2
• Using in contraindicated populations (severe renal/hepatic impairment, active major bleeding) 2, 3
• Inadequate patient education about missed dose management and bleeding precautions 3