What is the role of Eliquis (apixaban) in the treatment of Deep Vein Thrombosis (DVT)?

Eliquis (Apixaban) for Deep Vein Thrombosis Treatment

Apixaban is a first-line treatment for DVT that is preferred over warfarin due to significantly lower bleeding risk (69% reduction in major bleeding) while maintaining equivalent efficacy in preventing recurrent VTE. 1

Dosing Regimen

The standard dosing protocol is 10 mg orally twice daily for the first 7 days, followed by 5 mg twice daily for the remainder of treatment. 2, 1, 3

• No laboratory monitoring (INR) or dietary restrictions are required, eliminating the burden of frequent dose adjustments 1
• If a dose is missed, take it as soon as possible on the same day and resume the twice-daily schedule without doubling 3

Evidence Supporting Apixaban Over Warfarin

Major clinical guidelines from the American Society of Hematology and American College of Chest Physicians recommend DOACs, including apixaban, over vitamin K antagonists for DVT treatment in patients without cancer (Grade 1 recommendation). 1

The AMPLIFY trial demonstrated apixaban's superiority in safety outcomes: 2

• Major bleeding reduced by 69% compared to enoxaparin/warfarin (RR 0.31; 95% CI 0.17-0.55; P<0.001) 2
• Non-inferior efficacy for preventing recurrent symptomatic VTE (RR 0.84; 95% CI 0.60-1.18) 2
• Composite outcome of major bleeding plus clinically relevant non-major bleeding occurred in only 4.3% with apixaban versus 9.7% with conventional therapy 2

Real-world data confirms these findings, showing 27-39% reduction in major bleeding and 25-39% reduction in recurrent VTE across all time points and subgroups (PE with/without DVT, provoked/unprovoked VTE). 4

Treatment Duration Algorithm

For provoked DVT (surgery, pregnancy, transient risk factor): 2, 1

• Treat for exactly 3 months, then discontinue anticoagulation
• Do not extend therapy beyond 3 months—this exposes patients to unnecessary bleeding risk without meaningful VTE reduction benefit 1

For unprovoked DVT: 2, 1

• Treat for minimum 3 months with standard dosing (5 mg twice daily after initial 7 days)
• Consider indefinite therapy with no scheduled stop date
• After ≥6 months of treatment, may reduce to 2.5 mg twice daily for extended prevention 2, 3
• Reassess risks and benefits at least annually 2

Critical Contraindications and Cautions

Absolute contraindications: 1, 5

• Severe renal impairment (CrCl <15 mL/min)
• Severe hepatic impairment
• Antiphospholipid syndrome (use LMWH instead)

Use with caution in: 1, 5

• Moderate renal dysfunction (27% of drug undergoes renal elimination)
• Patients requiring dose reduction: Consider clinical context, as apixaban has predictable pharmacokinetics

Special Population: Cancer-Associated DVT

For cancer-associated DVT, LMWH remains first-line therapy per American Society of Clinical Oncology guidelines, though apixaban is an acceptable alternative. 1

• Apixaban has shown lower or similar rates of recurrent VTE compared to dalteparin in cancer patients 5
• No increased bleeding risk compared to LMWH in this population 6

Perioperative Management

Discontinue apixaban at least 48 hours before elective surgery with moderate-to-high bleeding risk, or 24 hours before procedures with low bleeding risk. 3

• Bridging anticoagulation during the 24-48 hour interruption is not generally required 3
• Restart as soon as adequate hemostasis is established 3

Common Pitfalls to Avoid

• Do not continue extended anticoagulation for provoked DVT—this is the most common error that exposes patients to bleeding without benefit 1
• Do not use apixaban in antiphospholipid syndrome—these patients require LMWH or warfarin 1
• Do not double the dose if one is missed—simply resume the regular twice-daily schedule 3
• Do not use initial parenteral anticoagulation—apixaban's dosing regimen eliminates this need, unlike warfarin 1, 7