Should a patient on Eliquis (Apixaban) with a new DVT receive Lovenox (Enoxaparin)?

From the Guidelines

No, a patient on Eliquis (Apixaban) with a new DVT should not receive Lovenox (Enoxaparin) as initial treatment is not necessary when already on a Direct Oral Anticoagulant (DOAC) like Apixaban.

Guidance for Anticoagulation Therapy

• According to the Chest guidelines 1, in patients with acute VTE, apixaban is recommended over VKA as treatment phase anticoagulant therapy, and initial treatment with parenteral anticoagulation is recommended when using VKA therapy, not when using DOACs like apixaban.
• The guidelines suggest that patients with acute VTE who are treated with a DOAC like apixaban do not require initial parenteral anticoagulation 1.
• The 2016 Chest guideline and expert panel report 1 also supports the use of apixaban as a long-term anticoagulant therapy for patients with DVT of the leg or PE, without requiring initial parenteral anticoagulation.

Clinical Considerations

• The patient is already on apixaban, which is a recommended treatment for acute VTE, and adding Lovenox (Enoxaparin) would not provide additional benefit and may increase the risk of bleeding.
• The guidelines recommend against offering extended-phase anticoagulation in patients with VTE diagnosed in the setting of a major transient risk factor, but this patient's situation does not indicate a need for extended-phase anticoagulation with a parenteral agent like Lovenox.

From the FDA Drug Label

In the AMPLIFY study, patients with an objectively confirmed symptomatic DVT and/or PE were randomized to treatment with apixaban 10 mg twice daily orally for 7 days followed by apixaban 5 mg twice daily orally for 6 months, or enoxaparin 1 mg/kg twice daily subcutaneously for at least 5 days (until INR ≥2) followed by warfarin (target INR range 2.0-3.0) orally for 6 months.

The patient on Eliquis (Apixaban) with a new DVT should not necessarily receive Lovenox (Enoxaparin) as the initial treatment for the new DVT, as apixaban is effective for the treatment of DVT and can be continued. However, the decision to add or switch to enoxaparin should be made on a case-by-case basis, considering the individual patient's risk factors and clinical circumstances. 2

From the Research

Treatment of New DVT in Patients on Apixaban

• The decision to use Lovenox (Enoxaparin) in a patient on Eliquis (Apixaban) with a new Deep Vein Thrombosis (DVT) depends on various factors, including the patient's individual risk of recurrent VTE and bleeding [(3,4)].
• Studies have shown that apixaban is noninferior to enoxaparin/warfarin in preventing recurrent symptomatic VTE or VTE-related death, with significantly less bleeding [(3,5)].
• In patients with active malignancy and acute DVT, apixaban was found to be as effective and safe as low-molecular-weight heparin (LMWH) 6.
• However, cases of treatment failure with apixaban have been reported, highlighting the need for close monitoring and individualized treatment 7.

Considerations for Treatment

• The risk of major bleeding and recurrent VTE should be carefully assessed in patients on apixaban with a new DVT [(4,6)].
• The use of enoxaparin in addition to apixaban may be considered in patients at high risk of recurrent VTE, but this should be balanced against the increased risk of bleeding [(3,5)].
• The decision to use enoxaparin should be made on a case-by-case basis, taking into account the patient's individual clinical characteristics and risk factors [(4,6)].