Duration of Eliquis (Apixaban) for DVT: Provoked vs Unprovoked
For provoked DVT, stop Eliquis at exactly 3 months; for unprovoked proximal DVT with low-to-moderate bleeding risk, continue indefinitely with annual reassessment. 1, 2
Provoked DVT Treatment Duration
Stop anticoagulation at 3 months for provoked DVT when the provoking factor is reversible. 1, 2
- Patients with surgery-provoked DVT have an annual recurrence risk <1% after completing 3 months of treatment, making extended therapy unnecessary. 1
- For hormone-associated DVT, discontinue hormonal therapy before stopping anticoagulation at 3 months. 1, 2
- The 3-month endpoint represents completion of "active treatment" of the acute thrombotic event. 1
Unprovoked DVT Treatment Duration
Initial 3-Month Period (All Patients)
- All patients with unprovoked DVT require a minimum of 3 months of therapeutic anticoagulation to prevent thrombus extension and early recurrence. 1
- The FDA-approved dosing is apixaban 10 mg twice daily for 7 days, followed by 5 mg twice daily. 3
Extended Therapy Decision (After 3 Months)
For unprovoked proximal DVT, continue anticoagulation indefinitely rather than stopping at 3 months, provided bleeding risk is not prohibitively high. 1, 2
- The annual recurrence risk exceeds 5% after stopping anticoagulation in unprovoked cases, which substantially outweighs bleeding risk in most patients. 1, 2
- The benefit of anticoagulation continues only as long as therapy is maintained—stopping treatment eliminates protection. 1
Bleeding Risk Stratification
Low-to-moderate bleeding risk patients should continue indefinitely (Grade 2B recommendation). 1, 2
Low bleeding risk criteria: 1
- Age <70 years
- No previous major bleeding episodes
- No concomitant antiplatelet therapy
- No severe renal or hepatic impairment
- Good medication adherence
High bleeding risk patients should stop at 3 months (Grade 1B recommendation). 1, 2
High bleeding risk criteria: 1
- Age ≥80 years
- Previous major bleeding
- Recurrent falls
- Need for dual antiplatelet therapy
- Severe renal or hepatic impairment
Special Consideration: Distal (Calf) DVT
- For unprovoked isolated distal DVT (not extending into popliteal vein), anticoagulation beyond 3 months is not required due to lower recurrence risk. 1
- Critical pitfall: Do not confuse distal DVT with proximal DVT—this distinction fundamentally changes treatment duration. 1
Dosing for Extended Therapy
For extended treatment beyond the initial 6 months, apixaban 2.5 mg twice daily is an option. 3
- The AMPLIFY-EXT trial demonstrated that both apixaban 2.5 mg and 5 mg twice daily were superior to placebo for preventing recurrent VTE (3.8% vs 11.6% for 2.5 mg dose, p<0.0001). 3
- The lower 2.5 mg dose provides effective prevention with potentially reduced bleeding risk for long-term therapy. 3
Mandatory Ongoing Management
Annual reassessment is required for all patients on extended anticoagulation. 1, 2
Evaluate at each assessment: 1, 2
- Bleeding risk factors (age, falls, new medications)
- Medication adherence
- Patient preference and tolerance
- Hepatic and renal function
Critical Clinical Pitfalls
- Do not use fixed time periods beyond 3 months (e.g., 6 months, 12 months) for unprovoked proximal DVT—the recommendation is either 3 months or indefinite. 1
- Do not treat all VTE the same—failing to distinguish provoked from unprovoked leads to both overtreatment and undertreatment. 1
- Do not rely on D-dimer testing alone to decide on stopping anticoagulation—a 2022 study showed unacceptably high recurrence rates (7.3%) when stopping anticoagulation based on negative D-dimer in unprovoked VTE patients. 4
- Indefinite does not mean permanent—it means no scheduled stop date with ongoing reassessment, and treatment can be discontinued if bleeding risk becomes prohibitive. 1
Second Unprovoked Event
For a second unprovoked DVT, extended anticoagulation is strongly recommended regardless of bleeding risk category (Grade 1B for low risk, Grade 2B for moderate risk). 2