Can an elderly female patient with a history of Deep Vein Thrombosis (DVT) over 3 years ago safely discontinue anticoagulation therapy with Eliquis (apixaban)?

Can This Patient Safely Discontinue Eliquis?

This patient can likely discontinue Eliquis after 3 years of treatment, but the decision hinges critically on whether the original DVT was provoked or unprovoked and her current bleeding risk.

Critical First Step: Determine DVT Provocation Status

The single most important factor determining whether to stop anticoagulation is whether the DVT 3 years ago was provoked or unprovoked 1:

If the DVT was provoked by a major transient risk factor (surgery, major trauma, prolonged immobilization):

• Stop Eliquis now - extended anticoagulation beyond 3 months is not recommended 1
• Annual recurrence risk after stopping is <1% 2
• No further anticoagulation is needed 1

If the DVT was provoked by a minor transient risk factor (minor surgery, estrogen therapy, minor injury):

• Stopping at 3 months was appropriate - extended therapy is generally not recommended 1
• If hormone-associated, stopping is strongly recommended if hormones were discontinued 1, 2

If the DVT was unprovoked (no identifiable trigger):

• This requires careful bleeding risk assessment before stopping 1
• Annual recurrence risk exceeds 5% after stopping anticoagulation 2

Bleeding Risk Assessment for Unprovoked DVT

If the DVT was unprovoked, assess bleeding risk using these specific factors 1, 2:

HIGH bleeding risk (stop Eliquis):

• Age ≥80 years 1, 2
• Previous major bleeding episode 1, 2
• Recurrent falls 1, 2
• Requires dual antiplatelet therapy (aspirin + clopidogrel) 1, 2
• Severe renal or hepatic impairment 1, 2

LOW-MODERATE bleeding risk (continue Eliquis indefinitely):

• Age <70 years 1, 2
• No previous bleeding episodes 1, 2
• No concomitant antiplatelet therapy 1, 2
• No renal or hepatic impairment 1, 2
• Good medication adherence 1, 2

Specific Recommendations Based on Scenario

For Unprovoked DVT with Low-Moderate Bleeding Risk:

• Continue extended anticoagulation indefinitely (no scheduled stop date) 1
• Consider switching to reduced-dose apixaban 2.5 mg twice daily instead of stopping - this provides effective prevention with lower bleeding risk 1, 3
• Mandatory annual reassessment of bleeding risk and patient preference 1, 3

For Unprovoked DVT with High Bleeding Risk:

• Stop Eliquis - bleeding risks outweigh recurrence prevention benefits 1
• Consider aspirin for secondary prevention if no contraindication (though much less effective than anticoagulation) 1, 3

Important Caveats and Pitfalls

Do NOT stop anticoagulation if:

• The patient has active cancer - extended therapy is strongly recommended regardless of bleeding risk 1
• This is a second unprovoked VTE - extended therapy is strongly recommended even with moderate bleeding risk 1

Common errors to avoid:

• Treating all DVTs the same without determining provocation status 2
• Using arbitrary time limits (like "3 years is enough") for unprovoked VTE - the guidelines recommend indefinite therapy for low-moderate bleeding risk, not time-limited treatment 1, 3
• Assuming elderly age alone is a contraindication - age <80 years with no other bleeding risk factors still favors continuation 1, 2

If the patient insists on stopping despite unprovoked DVT and low bleeding risk:

• Offer aspirin as inferior alternative for secondary prevention 1, 3
• Counsel that aspirin is much less effective than anticoagulation 1, 3
• Consider D-dimer testing one month after stopping - positive D-dimer strengthens the case for restarting anticoagulation 1, 4

Practical Algorithm

1. Review original DVT documentation - was there a clear provoking factor? 1
2. If provoked by major transient factor → Stop Eliquis 1
3. If unprovoked → Assess bleeding risk using age, bleeding history, falls, antiplatelet use, organ function 1, 2
4. If high bleeding risk → Stop Eliquis, consider aspirin 1
5. If low-moderate bleeding risk → Continue indefinitely with reduced-dose apixaban 2.5 mg BID 1, 3
6. Reassess annually regardless of decision 1, 3