What is the recommended treatment regimen for a patient with Deep Vein Thrombosis (DVT) on Eliquis (Apixaban)?

Treatment of Deep Vein Thrombosis with Apixaban (Eliquis)

For a patient with DVT on Eliquis, initiate treatment with apixaban 10 mg orally twice daily for the first 7 days, then reduce to 5 mg twice daily for the remainder of the initial 3-month treatment phase. 1, 2

Initial Treatment Phase (First 3 Months)

• Start with apixaban 10 mg orally twice daily for exactly 7 days, followed by 5 mg orally twice daily to complete a minimum 3-month treatment course 1, 2
• This regimen is strongly recommended over vitamin K antagonists (VKAs) based on moderate-certainty evidence showing similar efficacy with significantly lower major bleeding rates 1
• No parenteral anticoagulation (heparin) is required when initiating apixaban, unlike dabigatran or edoxaban which require 5-10 days of parenteral therapy first 1
• Patients can be treated at home if circumstances are adequate (stable living conditions, family support, phone access, ability to return if deterioration occurs) 1

Duration Decision After 3 Months

The critical decision point occurs at 3 months—you must determine whether to stop or continue anticoagulation:

Stop anticoagulation at 3 months if:

• DVT was provoked by major surgery 1
• DVT was provoked by a nonsurgical transient risk factor (trauma, immobilization, estrogen therapy) AND the patient has low-to-moderate bleeding risk 1

Continue extended anticoagulation (no scheduled stop date) if:

• DVT was unprovoked (no identifiable trigger) 1, 3
• Persistent risk factors remain present (active cancer, antiphospholipid syndrome, ongoing immobility) 1, 3
• Patient has recurrent VTE despite adequate treatment 1

Extended Treatment Phase (After 6 Months)

For patients continuing beyond 6 months, reduce to apixaban 2.5 mg orally twice daily rather than continuing the full 5 mg twice daily dose 1, 3

• This reduced dose provides effective secondary prevention with lower bleeding risk 1, 3
• Alternative option: continue 5 mg twice daily if higher thrombotic risk persists, though 2.5 mg twice daily is generally preferred 1
• Reassess the need for continued anticoagulation at least annually and with any significant health status changes 1, 3

Special Populations

Cancer-Associated DVT:

• Apixaban is strongly recommended over low-molecular-weight heparin (LMWH) for both initial and extended treatment 1
• Critical caveat: If the patient has a luminal gastrointestinal malignancy, apixaban may be preferred over rivaroxaban or edoxaban due to lower GI bleeding risk 1
• Continue anticoagulation at least until cancer resolution 1

Antiphospholipid Syndrome:

• Use warfarin (target INR 2.5) instead of apixaban if confirmed antiphospholipid syndrome is present 1
• This is based on evidence showing DOACs may be less effective in this specific population 1

Dose Adjustments and Drug Interactions

Reduce apixaban dose by 50% when coadministered with:

• Combined P-glycoprotein AND strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir, clarithromycin) 2
• If already on 2.5 mg twice daily, avoid these drug combinations entirely 2

Renal impairment:

• Avoid apixaban if creatinine clearance <15 mL/min 3, 2
• Monitor renal function regularly, especially in elderly patients 3

Switching Anticoagulants

From warfarin to apixaban:

• Discontinue warfarin and start apixaban when INR drops below 2.0 2

From apixaban to warfarin:

• Discontinue apixaban and simultaneously start both parenteral anticoagulant and warfarin at the time of the next scheduled apixaban dose 2
• Continue parenteral anticoagulant until INR reaches therapeutic range 2

From/to other anticoagulants:

• Simply discontinue one and start the other at the time of the next scheduled dose—no overlap needed 2

Critical Safety Considerations

Premature discontinuation warning:

• Never abruptly stop apixaban without bridging to another anticoagulant unless completing a planned treatment course or managing pathological bleeding 2
• Premature discontinuation significantly increases thrombotic event risk 2

Neuraxial procedures (spinal/epidural):

• Discontinue apixaban at least 48 hours before procedures with moderate-to-high bleeding risk 2
• Discontinue at least 24 hours before low-bleeding-risk procedures 2
• Epidural hematoma risk is substantial and can cause permanent paralysis 2
• Restart only after adequate hemostasis is established 2

Bleeding risk factors to monitor:

• Concomitant antiplatelet agents (aspirin, clopidogrel) 2
• NSAIDs 2
• Age >75 years, weight <60 kg, or renal impairment 2

Common Pitfalls to Avoid

• Do not use the atrial fibrillation dose (5 mg twice daily from day 1) for DVT treatment—the initial 7-day loading phase with 10 mg twice daily is essential 1, 2
• Do not continue full-dose (5 mg twice daily) indefinitely without considering dose reduction to 2.5 mg twice daily after 6 months 1, 3
• Do not assume all DOACs are equivalent—apixaban does not require parenteral lead-in, unlike dabigatran and edoxaban 1
• Do not forget to reassess annually—extended therapy requires ongoing risk-benefit evaluation 1, 3