Should a patient with a history of Deep Vein Thrombosis (DVT) continue taking aspirin while on Eliquis (apixaban) for DVT treatment and prevention?

Should You Continue Aspirin with Eliquis for DVT?

No, you should stop aspirin when starting Eliquis (apixaban) for DVT treatment unless you have a specific compelling cardiovascular indication that requires continued antiplatelet therapy. 1, 2

Primary Recommendation for Uncomplicated DVT

• For patients with DVT who were taking aspirin for primary prevention of cardiovascular disease, stop aspirin immediately when starting anticoagulation. 1, 2
• The American Society of Hematology specifically recommends suspending aspirin for the duration of anticoagulation therapy in patients with DVT or PE who have stable cardiovascular disease. 2
• Combining aspirin with anticoagulants increases major bleeding risk (RR 1.26; 95% CI 0.92-1.72) without providing additional benefit for VTE treatment. 2

When Aspirin Should Be Continued with Eliquis

The 2020 ACC Expert Consensus provides clear time-based algorithms for specific cardiovascular conditions 1:

Recent Percutaneous Coronary Intervention (PCI)

• <6 months since PCI: Stop aspirin, continue clopidogrel, and start Eliquis 1
• 6-12 months since PCI: Continue single antiplatelet therapy (aspirin OR clopidogrel) with Eliquis until 1 year post-PCI 1
• >12 months since PCI: Stop all antiplatelet therapy and use Eliquis alone 1

Recent Acute Coronary Syndrome (ACS)

• <12 months since ACS: Stop aspirin, continue clopidogrel (not aspirin), and start Eliquis 1
• >12 months since ACS: Stop all antiplatelet therapy and use Eliquis alone 1
• Exception: Selected high-risk patients (complex coronary lesions, multiple stents) at low bleeding risk may continue single antiplatelet therapy beyond 12 months at clinician discretion 1

Recent CABG Surgery

• <1 year post-CABG: Continue aspirin (<100 mg/day) with Eliquis 1
• >1 year post-CABG: Stop aspirin and use Eliquis alone 1

Peripheral Artery Disease (PAD)

• PAD without intervention: Stop all antiplatelet therapy and use Eliquis alone 1
• PAD with recent endovascular stenting (1-3 months): Continue or switch to single antiplatelet therapy with Eliquis 1

Cerebrovascular Disease

• Prior stroke/TIA: Stop all antiplatelet therapy when safe from hemorrhagic transformation perspective (typically 2-14 days after acute event) and use Eliquis alone 1

Critical Bleeding Risk Considerations

• The combination of aspirin and anticoagulation significantly increases bleeding risk without improving VTE outcomes. 2
• If aspirin must be continued with Eliquis for a cardiovascular indication, use the lowest effective dose (75-100 mg daily) and initiate a proton pump inhibitor for GI protection. 2
• Patients requiring combined therapy should be closely monitored for bleeding complications, particularly gastrointestinal bleeding. 2

Common Pitfalls to Avoid

• Do not reflexively continue aspirin "for the heart" in patients with stable coronary disease or primary prevention—anticoagulation alone is appropriate and safer. 1, 2
• Do not use aspirin as a substitute for anticoagulation in DVT treatment—aspirin is vastly inferior, increasing recurrent VTE risk 3-fold compared to continued anticoagulation. 3
• Do not continue dual antiplatelet therapy (aspirin + clopidogrel) beyond the specific time frames outlined above—switch to single agent (preferably clopidogrel, not aspirin) when combining with anticoagulation. 1

Extended DVT Treatment Considerations

• After completing initial DVT treatment (typically 3-6 months), if extended anticoagulation is indicated for unprovoked DVT, consider reduced-dose apixaban (2.5 mg twice daily) rather than switching to aspirin. 1, 3
• Reduced-dose DOACs are superior to aspirin for preventing recurrent VTE (preventing 39 additional events per 1,000 patients over 2-4 years) with minimal additional bleeding risk. 3
• Aspirin should only be considered for extended VTE prevention if the patient refuses or cannot tolerate any form of anticoagulation. 3