When to stop Eliquis (apixaban) in a patient with a history of incidental small upper lobe pulmonary embolism?

Duration of Eliquis (Apixaban) for Incidental Small Upper Lobe Pulmonary Embolism

For an incidental small upper lobe PE, discontinue Eliquis after completing 3 months of therapeutic anticoagulation if the PE was provoked by a major transient risk factor that has resolved, or continue indefinitely (with dose reduction to 2.5 mg twice daily after 6 months) if the PE was unprovoked or associated with persistent risk factors. 1

Initial Treatment Phase (First 3 Months)

• All patients with PE, regardless of size or location, require a minimum of 3 months of therapeutic-dose anticoagulation to complete treatment of the acute episode and prevent early recurrence 1
• The standard dosing for apixaban during this initial phase is 10 mg orally twice daily for the first 7 days, then 5 mg orally twice daily for the remainder of treatment 2
• After completing this 3-month treatment phase, every patient must be assessed for extended-phase therapy based on their recurrence risk 1

Decision Algorithm for Stopping vs. Continuing Anticoagulation

Stop at 3 Months If:

Major Transient/Reversible Risk Factor Present (Low recurrence risk <3% per year):

• Surgery with general anesthesia >30 minutes 1
• Hospital admission requiring bed rest ≥3 days for acute illness 1
• Major trauma with fractures 1
• These patients have <1% annual recurrence risk after stopping anticoagulation 3
• Strong recommendation against extended anticoagulation in this scenario 1

High Bleeding Risk:

• Even if recurrence risk is elevated, high bleeding risk patients should stop after 3 months 3

Continue Indefinitely (Extended-Phase) If:

Unprovoked PE (No identifiable risk factor):

• Annual recurrence risk >8% after stopping anticoagulation 1
• Strong recommendation for extended-phase anticoagulation with a DOAC 1
• After completing 6 months of therapeutic dosing, transition to reduced-dose apixaban 2.5 mg twice daily 1, 3, 2

Persistent Risk Factors Present:

• Active cancer 1
• Active autoimmune disease 1
• Antiphospholipid antibody syndrome (though switch to warfarin, not DOAC) 2
• Previous unprovoked VTE episode 1

Intermediate Scenario - Shared Decision-Making:

Minor Transient Risk Factors (Intermediate recurrence risk 3-8% per year):

• Pregnancy/puerperium 1
• Bed rest at home ≥3 days 1
• Leg injury without fracture with reduced mobility 1
• Long-haul travel 1
• Weak recommendation against extended anticoagulation, but consider if low bleeding risk 1
• A 2025 trial showed that patients with provoked PE plus enduring risk factors had 10% recurrence with placebo vs. 1.3% with apixaban 2.5 mg twice daily over 12 months 4

Special Considerations for "Incidental" PE

• The incidental nature of the PE discovery does not change treatment duration recommendations 1
• Small size and upper lobe location do not reduce recurrence risk or justify shorter treatment 1
• The key determinant is whether the PE was provoked or unprovoked, not its size or how it was discovered 1

Extended-Phase Dosing Regimen

• After 6 months of therapeutic anticoagulation (5 mg twice daily), reduce to apixaban 2.5 mg twice daily for extended prophylaxis 1, 3, 2
• This reduced dose provides effective VTE prevention with lower bleeding risk compared to full therapeutic dosing 3
• Weak recommendation for reduced-dose over full-dose apixaban for extended therapy 1

Ongoing Monitoring Requirements

• Reassess the decision for extended anticoagulation at least annually 1
• Monitor for changes in bleeding risk, drug tolerance, adherence, and hepatic/renal function 2
• Extended anticoagulation does not have a predefined stop date, though most trial data extends 2-4 years 1
• The risk-benefit balance beyond 4 years is uncertain 1

Critical Pitfalls to Avoid

• Do not assume "incidental" or "small" PE requires less treatment - these factors do not predict lower recurrence risk 1
• Do not continue full therapeutic dosing indefinitely - transition to reduced-dose apixaban 2.5 mg twice daily after 6 months if extended therapy is chosen 3, 2
• Do not use apixaban in antiphospholipid syndrome - this is an absolute contraindication; use warfarin instead 2
• Do not forget that PE recurs as PE - patients with prior PE have twice the case fatality rate of recurrent VTE compared to those with prior DVT 1