Duration of Eliquis (Apixaban) Treatment for Pulmonary Embolism
For unprovoked PE with low or moderate bleeding risk, you should continue Eliquis indefinitely with annual reassessment, not stop at a fixed time point. 1, 2
Treatment Algorithm Based on PE Classification
Provoked PE (3 months, then stop)
If your PE was provoked by surgery, treat with anticoagulation for exactly 3 months, then stop—the annual recurrence risk is less than 1% after completing treatment. 3, 2 This is a Grade 1B recommendation against extending beyond 3 months. 3
If your PE was provoked by a non-surgical transient risk factor (trauma, immobilization, estrogen therapy), treat for 3 months as the standard duration. 3, 2 For women with hormone-associated PE, discontinue hormonal therapy before stopping anticoagulation. 1, 2
Unprovoked PE (Minimum 3 months, then risk-stratify)
All patients with unprovoked PE require at least 3 months of anticoagulation. 3, 1 After this initial period, the decision hinges on bleeding risk because unprovoked PE carries an annual recurrence risk exceeding 5% after stopping anticoagulation. 1, 2
For low or moderate bleeding risk: Extended (indefinite) anticoagulation is recommended over stopping at 3 months (Grade 2B). 3, 1 This means continuing Eliquis with no scheduled stop date, potentially lifelong or until bleeding risk becomes prohibitive. 1
For high bleeding risk: Stop anticoagulation at 3 months (Grade 1B). 3, 1
Eliquis Dosing Regimen
The FDA-approved dosing for PE treatment is: 4
- Days 1-7: 10 mg twice daily
- After day 7: 5 mg twice daily
For extended therapy to reduce recurrence risk after at least 6 months of treatment: 2.5 mg twice daily. 4 This lower dose is specifically for long-term prevention after completing the acute treatment phase.
Bleeding Risk Assessment
Low/moderate bleeding risk (suitable for indefinite therapy) includes: 1
- Age <70 years
- No previous major bleeding episodes
- No concomitant antiplatelet therapy
- No renal or hepatic impairment
- Good medication adherence
High bleeding risk (favors stopping at 3 months) includes: 1
- Age ≥80 years
- Previous major bleeding
- Recurrent falls
- Need for dual antiplatelet therapy
- Severe renal or hepatic impairment
Special Considerations
Second unprovoked PE: Extended anticoagulation is strongly recommended (Grade 1B for low bleeding risk, Grade 2B for moderate bleeding risk). 3, 1
Cancer-associated PE: Extended anticoagulation is recommended regardless of bleeding risk (Grade 1B for low/moderate risk, Grade 2B for high risk). 3 However, LMWH is preferred over DOACs for cancer-associated VTE. 5
Mandatory Ongoing Management
Annual reassessment is required for all patients on extended anticoagulation. 1, 2 This includes:
- Bleeding risk factors
- Medication adherence
- Patient preference
- Drug tolerance
- Hepatic and renal function 5
Critical Pitfalls to Avoid
Do not use fixed time-limited periods beyond 3 months (such as 6 or 12 months) for unprovoked PE—guidelines recommend either stopping at 3 months or continuing indefinitely based on bleeding risk. 3, 5 The benefit of anticoagulation continues only as long as therapy is maintained. 1, 2
Do not fail to distinguish between provoked and unprovoked PE—this is the strongest predictor of recurrence and determines treatment duration. 1, 2
Do not ignore that most recurrences occur after stopping anticoagulation—in one study, all but one recurrence happened after discontinuation, with 57.6% presenting as PE (including two fatal cases). 6
Evidence Quality Note
The AMPLIFY trial demonstrated that apixaban was non-inferior to enoxaparin/warfarin for treating acute VTE (including 1,836 PE patients), with significantly less major bleeding (0.6% vs 1.8%, P<0.001). 3, 7 This bleeding advantage began early during treatment, with major bleeding at 7 days occurring in 0.1% with apixaban versus 0.6% with conventional therapy. 8