How long should a patient with two deep vein thromboses (DVTs) in one year, one of which was provoked by a six-hour flight, stay on Eliquis (apixaban)?

Extended Anticoagulation Recommended for Recurrent DVT

You should continue Eliquis (apixaban) indefinitely with no planned stop date, given you have experienced two DVTs within one year—this represents recurrent unprovoked VTE with high bleeding risk considerations that warrant lifelong anticoagulation. 1

Why This Situation Requires Extended Anticoagulation

Your clinical scenario involves critical factors that determine duration:

The Flight-Associated DVT Is Likely Unprovoked

• A six-hour flight is considered a minor transient risk factor, not a major provocation like surgery or major trauma 1
• Minor transient risk factors (such as short flights, oral contraceptives, or minor injuries) do not substantially reduce recurrence risk compared to truly unprovoked events 1, 2
• Guidelines suggest against stopping anticoagulation at 3 months for VTE provoked by minor transient factors, as the annual recurrence risk remains elevated at >5% 1, 2

Recurrent VTE Changes Everything

• Having a second unprovoked VTE is the strongest indication for indefinite anticoagulation 1, 2
• The CHEST guidelines provide a Grade 1B recommendation (strong) for extended anticoagulation in patients with a second unprovoked VTE and low bleeding risk 1
• Even with moderate bleeding risk, extended therapy is suggested (Grade 2B) 1
• Your annual recurrence risk if you stop anticoagulation exceeds 10-15%, far outweighing typical bleeding risks 1, 2

Dosing Strategy for Extended Therapy

After completing 6 months of standard-dose apixaban (5 mg twice daily), you should transition to reduced-dose apixaban 2.5 mg twice daily for extended prevention. 1

• The CHEST 2021 guidelines suggest reduced-dose apixaban over full-dose for extended-phase anticoagulation (weak recommendation, very low-certainty evidence) 1
• The AMPLIFY-EXT trial demonstrated that apixaban 2.5 mg twice daily reduced recurrent VTE by 67% compared to placebo (3.8% vs 11.6%) with minimal increase in bleeding 3
• Recent evidence from the HI-PRO trial (2025) showed apixaban 2.5 mg twice daily reduced recurrent VTE by 87% (1.3% vs 10.0%) even in provoked VTE with enduring risk factors, with only 1 major bleeding event 4

Bleeding Risk Assessment Determines Final Decision

You need annual reassessment of these bleeding risk factors 1, 2:

Low bleeding risk factors (favor indefinite therapy):

• Age <70 years 2
• No previous major bleeding episodes 2
• No concomitant antiplatelet therapy 2
• No severe renal or hepatic impairment 2
• Good medication adherence 2

High bleeding risk factors (may favor stopping at 3 months):

• Age ≥80 years 2
• Previous major bleeding 2
• Recurrent falls 2
• Need for dual antiplatelet therapy 2
• Severe renal or hepatic impairment 2

If you have high bleeding risk, the recommendation shifts to stopping at 3 months (Grade 2B), but this is a weaker recommendation given your recurrent events. 1

Critical Management Points

• "Indefinite" means no scheduled stop date—potentially lifelong or until bleeding risk becomes prohibitive 1, 2
• The benefit of anticoagulation persists only while you continue taking it; stopping restarts your high recurrence risk immediately 1, 2
• You require mandatory annual reassessment of bleeding risk, medication adherence, renal function, and any new medical conditions 1, 5
• Do not confuse "indefinite" with "permanent"—the decision can be reversed if circumstances change 1, 2

Common Pitfalls to Avoid

• Do not treat the flight-associated DVT as truly "provoked" and stop at 3 months—minor transient risk factors do not confer the same low recurrence risk as major surgery 1, 2
• Do not use fixed time-limited periods (like 6 or 12 months) for recurrent unprovoked VTE—guidelines recommend against this approach 1, 2
• Do not fail to transition to reduced-dose apixaban after the initial treatment phase—this provides equivalent protection with potentially lower bleeding risk 1, 3