What is the recommended duration of anticoagulation with Eliquis (apixaban) for a patient with a pulmonary embolism (PE) that has decreased in size?

Duration of Eliquis (Apixaban) for Pulmonary Embolism

All patients with PE require a minimum of 3 months of therapeutic anticoagulation, but the decision to continue beyond this period depends on whether the PE was provoked or unprovoked—not on whether the clot has decreased in size. 1

Critical Decision Point: Provoked vs. Unprovoked PE

The size reduction of your PE is a positive sign of treatment response, but it does not determine anticoagulation duration. What matters is why the PE occurred:

If PE Was Provoked by a Major Transient Risk Factor

• Discontinue Eliquis after 3 months 1
• Major transient risk factors include: surgery, major trauma, prolonged immobilization, or hospitalization 1
• These patients have low recurrence risk (<1% annually) after stopping anticoagulation 1

If PE Was Unprovoked (No Identifiable Cause)

• Extended anticoagulation of indefinite duration should be considered 1, 2
• Unprovoked PE carries >5% annual recurrence risk, which exceeds the bleeding risk of continued anticoagulation 1, 3
• After 6 months of therapeutic-dose Eliquis (5 mg twice daily), consider reducing to 2.5 mg twice daily for extended therapy 1
• This reduced dose maintains efficacy while lowering bleeding risk 4

If This Is a Recurrent PE (Second Episode)

• Indefinite anticoagulation is recommended 1
• Recurrent VTE mandates lifelong therapy unless bleeding risk becomes prohibitive 5

Bleeding Risk Assessment

Your bleeding risk must be formally assessed to guide the extended anticoagulation decision:

• Low bleeding risk: Strongly favor indefinite anticoagulation 3
• Moderate bleeding risk: Still favor indefinite anticoagulation 3
• High bleeding risk: Consider stopping at 3 months even for unprovoked PE 3
• Reassess bleeding risk every 3-6 months if on extended therapy, checking liver/kidney function, drug adherence, and new bleeding risk factors 1

Important Caveats

• The benefit of anticoagulation lasts only as long as you take it—stopping therapy returns you to baseline recurrence risk immediately 1, 3
• Clot size reduction is expected with treatment but does not predict recurrence risk 6
• "Indefinite" means no predetermined stop date; it could be lifelong or until circumstances change (e.g., development of high bleeding risk) 1, 3
• If you have persistent risk factors (active cancer, antiphospholipid syndrome, ongoing immobility), extended anticoagulation is recommended regardless of whether this is your first PE 1

Practical Algorithm

1. Identify PE type: Provoked by major transient factor vs. unprovoked vs. recurrent
2. If provoked by major transient factor: Stop at 3 months 1
3. If unprovoked or recurrent: Assess bleeding risk
   • Low/moderate bleeding risk → Continue indefinitely, consider dose reduction to 2.5 mg twice daily after 6 months 1
   • High bleeding risk → Discuss risks/benefits; may stop at 3 months 3
4. Reassess every 3-12 months for bleeding risk changes, adherence, and organ function 1