How do I treat pulmonary embolism (PE) in a patient with erectile dysfunction (ED) who is taking Eliquis (apixaban)?

Treatment of Pulmonary Embolism in Patients Already Taking Eliquis (Apixaban)

If a patient already taking Eliquis (apixaban) develops a new pulmonary embolism in the ED, continue the apixaban but increase to the acute PE treatment dose of 10 mg twice daily for 7 days, then 5 mg twice daily thereafter. 1

Initial Assessment and Dosing Strategy

The critical first step is determining whether this represents treatment failure or inadequate dosing:

• Verify current apixaban dosing and adherence - Many patients may be on the 2.5 mg twice daily dose for recurrence prevention rather than the full treatment dose 1
• If the patient is on 2.5 mg twice daily (recurrence prevention dose), immediately escalate to 10 mg twice daily for 7 days, then 5 mg twice daily 1
• If the patient is already on 5 mg twice daily (standard treatment dose), still escalate to 10 mg twice daily for 7 days to ensure adequate acute-phase anticoagulation 1

Hemodynamic Stability Determines Treatment Pathway

For hemodynamically stable patients (systolic BP ≥90 mmHg):

• Continue or escalate apixaban dosing as above 2, 3
• Apixaban is FDA-approved for PE treatment and is non-inferior to LMWH/warfarin with lower bleeding risk 2, 3
• Direct oral anticoagulants like apixaban reduce major bleeding by 0.6% compared to traditional therapy 3

For hemodynamically unstable patients (systolic BP <90 mmHg):

• Do NOT continue apixaban alone - these patients require systemic thrombolysis 2, 1
• Apixaban is not recommended as an alternative to unfractionated heparin for initial treatment of PE patients presenting with hemodynamic instability 1
• Systemic thrombolysis reduces absolute mortality by 1.6% (from 3.9% to 2.3%) in hypotensive PE patients 3
• After hemodynamic stabilization with thrombolysis, transition back to apixaban at treatment doses 2

Critical Considerations for Treatment Failure

If the patient was already on therapeutic-dose apixaban (5 mg or 10 mg twice daily) and developed recurrent PE:

• Assess for adherence issues - missed doses are the most common cause of apparent treatment failure 1
• Check renal function - apixaban is contraindicated in severe renal impairment (CrCl <30 mL/min) where it may be ineffective 2, 4
• Consider alternative diagnoses - ensure this is truly a new PE and not chronic thromboembolic disease 2
• Evaluate for underlying malignancy - cancer patients have 20% recurrence rates and may require LMWH instead 2

Special Populations Requiring Alternative Therapy

Switch from apixaban to LMWH if:

• Active malignancy is present - LMWH (dalteparin 200 U/kg daily for 4-6 weeks, then 75% dose) is superior to oral anticoagulants in cancer patients 2
• Severe renal impairment (CrCl <30 mL/min) - apixaban is not recommended 2, 4
• Triple-positive antiphospholipid syndrome - DOACs have increased thrombotic event rates compared to warfarin in these patients 1

Common Pitfalls to Avoid

• Do not add parenteral anticoagulation on top of therapeutic apixaban - this increases bleeding risk without proven benefit in stable patients 2
• Do not use anti-Xa levels or INR to guide apixaban dosing - these tests are not useful for monitoring apixaban effect 1
• Do not delay treatment escalation while awaiting subspecialty consultation - immediate dose adjustment is critical 1
• Do not assume all patients on apixaban are on treatment doses - verify the actual dose being taken 1

Disposition and Follow-up

• Low-risk PE patients (PESI class I-II, sPESI = 0) on appropriate apixaban dosing can be considered for early discharge 2
• Intermediate-risk patients should be admitted for observation and reassessment at 48 hours 2
• All patients require close follow-up within 5-7 days to reassess symptoms and ensure proper dosing 5