What is the preferred treatment between Eliquis (apixaban) and rivaroxaban for a patient with deep vein thrombosis (DVT) and normal renal function?

Apixaban vs Rivaroxaban for DVT

For patients with DVT and normal renal function, apixaban is the preferred agent over rivaroxaban due to its superior bleeding safety profile, simpler dosing transition, and lower major bleeding rates demonstrated in head-to-head comparative data. 1

Efficacy: Equivalent Outcomes

Both agents demonstrate comparable efficacy for DVT treatment:

• Apixaban showed non-inferiority to conventional enoxaparin/warfarin therapy with a relative risk of 0.84 (95% CI 0.60-1.18) for recurrent VTE 1
• Rivaroxaban demonstrated non-inferiority with a hazard ratio of 1.12 (95% CI 0.75-1.68) for recurrent symptomatic VTE 1
• For secondary prevention after 6 months, both reduced-dose apixaban (2.5 mg BID) and rivaroxaban (10 mg daily) show similar efficacy with no significant difference in DVT recurrence rates 1

Bleeding Safety: Apixaban's Advantage

The critical differentiator is bleeding risk, where apixaban demonstrates superior safety:

• Apixaban achieved significantly lower major bleeding rates compared to conventional therapy (RR 0.31; 95% CI 0.17-0.55; P <0.001) 1
• Rivaroxaban showed lower major bleeding than conventional therapy (1.1% vs 2.2%, HR 0.49) but this advantage was less pronounced than apixaban's 1
• The composite outcome of major plus clinically relevant non-major bleeding occurred in only 4.3% with apixaban versus 9.7% with conventional therapy (RR 0.44; P <0.001) 1

Dosing Considerations

Apixaban offers a simpler transition:

• Initial: 10 mg twice daily for 7 days, then 5 mg twice daily 1
• No parenteral anticoagulation required 1

Rivaroxaban requires more complex dosing:

• Initial: 15 mg twice daily with food for 21 days, then 20 mg daily with food 1
• Must be taken with food for proper absorption 1

Renal Clearance Profile

• Apixaban: Only 27% renally cleared, safer in mild-moderate renal impairment 1, 2
• Rivaroxaban: Primarily eliminated via kidneys, requiring more caution with renal dysfunction 1

Special Population Considerations

For gastrointestinal malignancies:

• Apixaban may be safer than rivaroxaban in patients with gastric or gastroesophageal lesions (major bleeding 3.8% vs higher rates with other DOACs) 1
• The NCCN panel specifically notes apixaban as potentially safer for GI cancer patients 1

For cancer-associated DVT:

• Both agents receive category 1 recommendations from NCCN, though apixaban demonstrates more favorable bleeding profiles in GI malignancies 1

Extended Therapy

After completing initial treatment (6 months):

• Apixaban: 2.5 mg twice daily for secondary prevention 1
• Rivaroxaban: 10 mg daily for secondary prevention 1
• Both reduced-dose regimens show similar efficacy without significant differences in recurrent VTE or major bleeding 1

Common Pitfalls

• Rivaroxaban food requirement: Failure to take rivaroxaban with food reduces absorption and efficacy 1
• Dose confusion: The VTE treatment dose of rivaroxaban (20 mg daily maintenance) differs from the atrial fibrillation dose (15 mg daily) 1
• Renal monitoring: Both require renal function assessment, but rivaroxaban demands more vigilant monitoring given higher renal clearance 1