What is the recommended follow-up schedule for a patient on apixaban (Direct Oral Anticoagulant) for chronic Deep Vein Thrombosis (DVT)?

Follow-Up Schedule for Patients on Apixaban for Chronic DVT

Patients on apixaban for chronic DVT should be reassessed at least annually to evaluate the continued need for anticoagulation, bleeding risk, and any changes in health status. 1

Initial Assessment Timeline

3-Month Evaluation (Critical Decision Point)

• All patients must be assessed at 3 months to determine whether to continue or discontinue anticoagulation 1
• This assessment determines eligibility for extended-phase therapy (anticoagulation with no scheduled stop date) 1

Decision Framework at 3 Months

For provoked DVT (major transient risk factor such as surgery):

• Stop anticoagulation after 3 months 1, 2, 3
• No further follow-up for anticoagulation is needed unless new VTE occurs 1

For unprovoked DVT or persistent risk factors:

• Offer extended-phase anticoagulation with apixaban beyond 3 months 1
• Transition to reduced-dose apixaban 2.5 mg twice daily (from the standard 5 mg twice daily) for extended therapy 1, 4

Extended-Phase Follow-Up Schedule

Annual Reassessment (Mandatory)

Patients receiving extended-phase anticoagulation must be reevaluated at least annually to assess: 1

• Bleeding risk factors: Age, prior bleeding history, renal function (creatinine clearance), hepatic function, thrombocytopenia, hypertension, concurrent antiplatelet therapy, anemia, alcohol use, fall risk 1
• Recurrent VTE risk: Presence of new transient or persistent risk factors 1
• Patient preference and quality of life: Burden of therapy, adherence, lifestyle changes 1
• Changes in health status: New comorbidities, medications, or conditions affecting bleeding/thrombosis risk 1

Additional Reassessment Triggers

Evaluate anticoagulation continuation at any time when: 1

• Significant change in health status occurs (new cancer diagnosis, renal failure, major surgery planned)
• Major bleeding event occurs
• Patient develops new contraindications to anticoagulation
• Patient expresses concerns about continuing therapy

Important Caveats

Duration Uncertainty Beyond 2-4 Years

• While extended-phase therapy has "no scheduled stop date," the longest follow-up data from clinical trials is approximately 2-4 years 1
• The risk-benefit balance beyond 4 years is uncertain, requiring particularly careful annual reassessment 1

High Bleeding Risk Patients

• Patients with high bleeding risk should not receive extended-phase therapy and should stop anticoagulation at 3 months 1
• High bleeding risk includes: severe thrombocytopenia, active cancer with high bleeding potential, severe hepatic/renal impairment, recent major bleeding 1

Renal Function Monitoring

• Apixaban should be avoided in severe renal impairment (CrCl <15 mL/min) 2, 4
• Use caution with CrCl <25 mL/min and monitor renal function at each annual visit 4

Common Pitfalls to Avoid

• Do not continue extended anticoagulation for provoked DVT beyond 3 months—this exposes patients to unnecessary bleeding risk without meaningful VTE reduction benefit 2
• Do not skip the 3-month assessment—this is the critical decision point for all patients 1
• Do not forget to reduce the apixaban dose to 2.5 mg twice daily when transitioning to extended-phase therapy after 6 months 1, 4
• Do not continue indefinite anticoagulation without annual reassessment—bleeding risk and patient circumstances change over time 1