How to manage Deep Vein Thrombosis (DVT) in a patient already on Eliquis (apixaban)?

Management of DVT in a Patient Already on Eliquis (Apixaban)

If a patient develops DVT while already taking apixaban at therapeutic doses and is believed to be compliant, switch to low molecular weight heparin (LMWH) at least temporarily. 1

Initial Assessment

When a patient on apixaban develops DVT, this represents breakthrough thrombosis on anticoagulation, which is unusual and requires immediate evaluation:

• Confirm the diagnosis with objective imaging to ensure this is truly a new or recurrent DVT 1
• Verify medication compliance through careful history, pharmacy records, and patient interview 1
• Evaluate for underlying malignancy as occult cancer is a common cause of anticoagulation failure 1
• Review the current apixaban dosing to ensure the patient is on the correct therapeutic dose (10 mg twice daily for first 7 days, then 5 mg twice daily for DVT treatment) 1, 2

Recommended Management Strategy

Switch to LMWH

The CHEST guidelines specifically recommend switching to LMWH for at least 1 month when patients experience recurrent VTE on therapeutic DOAC therapy 1. This applies to patients on apixaban, dabigatran, rivaroxaban, or edoxaban who are believed to be compliant 1.

LMWH Dosing

• Standard dosing: Enoxaparin 1 mg/kg subcutaneously twice daily or 1.5 mg/kg once daily 1
• In cancer patients: Dalteparin 200 units/kg subcutaneously once daily for 1 month, then 150 IU/kg once daily for months 2-6 1

Duration of LMWH

Continue LMWH for at least 1 month before considering transition back to oral anticoagulation 1. If the patient remains on LMWH long-term and experiences another recurrent VTE, increase the LMWH dose by approximately one-quarter to one-third 1.

Special Considerations

If Cancer is Discovered

If malignancy is identified during workup, LMWH or oral factor Xa inhibitors (apixaban, edoxaban, rivaroxaban) are preferred over warfarin 1. For cancer-associated VTE, apixaban has demonstrated noninferiority to dalteparin without increased major bleeding risk 3, and both apixaban and edoxaban receive Category 1 recommendations from NCCN 1.

If Patient Was on Subtherapeutic Dosing

If the patient was taking apixaban 2.5 mg twice daily (the reduced dose for secondary prevention after 6 months) rather than the therapeutic 5 mg twice daily dose:

• Increase to therapeutic dosing: 10 mg twice daily for 7 days, then 5 mg twice daily 1, 2
• Do not switch to LMWH unless breakthrough occurs on confirmed therapeutic dosing 1

If Compliance is Questionable

• Address barriers to adherence including cost, dosing complexity, and patient understanding 1
• Consider LMWH as it can be administered by visiting nurses or family members if self-administration is unreliable 1
• Supervised anticoagulation may be necessary in some cases 1

Common Pitfalls to Avoid

• Do not simply increase the apixaban dose beyond FDA-approved dosing, as there is no evidence supporting this approach and it increases bleeding risk 2
• Do not assume non-compliance without investigation - true anticoagulation failure can occur and requires alternative therapy 1
• Do not overlook cancer screening - breakthrough thrombosis is a red flag for occult malignancy 1
• Do not use bridging therapy when switching from apixaban to LMWH, as apixaban can be stopped and LMWH started immediately 2

Long-Term Management

After the acute phase on LMWH, decisions about extended anticoagulation should consider:

• Indefinite anticoagulation is recommended for unprovoked VTE or VTE with persistent risk factors 1
• If returning to oral therapy, consider whether the initial failure was due to compliance issues, drug interactions, or true therapeutic failure 1
• If cancer-associated, continue anticoagulation indefinitely unless bleeding risk is prohibitive 1