When can a 22-year-old female with a history of deep vein thrombosis (DVT) in the calf, initially triggered by birth control pills and prolonged immobility, and treated with Apixaban (Elequise) twice daily for 6 months, safely stop taking Apixaban now that she has discontinued birth control pills and remains symptom-free?

When to Stop Apixaban After Provoked Calf DVT

This patient can stop apixaban now, as she has completed 6 months of anticoagulation for a provoked calf DVT and the provoking factors (birth control pills and immobility) have been eliminated. 1, 2

Classification of This DVT

This DVT is provoked by transient risk factors (combined oral contraceptives and prolonged immobility during travel), which fundamentally determines the treatment duration. 3

• Hormone-associated DVT carries approximately 50% lower recurrence risk compared to unprovoked VTE 1, 4
• After discontinuing hormonal therapy and completing 3 months of anticoagulation, the annual recurrence risk drops to less than 1% 1, 2
• Calf (distal) DVT has about half the recurrence risk of proximal DVT or PE 3

Duration of Anticoagulation Completed

The minimum required treatment duration has been exceeded:

• All DVT patients require at least 3 months of therapeutic anticoagulation to prevent thrombus extension and early recurrence 3, 2
• For unprovoked calf DVT, guidelines suggest 3 months of treatment 3
• For provoked DVT with transient risk factors, 3 months is sufficient and anticoagulation beyond this is not routinely required 3
• This patient has completed 6 months, which exceeds all guideline recommendations for provoked calf DVT 1, 2

How to Stop Apixaban

Simply discontinue the medication—no tapering is required:

• DOACs like apixaban do not require dose tapering or bridging when stopping 5
• The medication can be stopped abruptly after the final dose 5
• No INR monitoring or transition to another anticoagulant is needed 5

Critical Contraindication Going Forward

Birth control pills are now permanently contraindicated for this patient:

• Developing DVT while on any form of hormonal contraception represents an absolute contraindication to resumption 1
• This applies to all forms of hormonal contraception (oral, transdermal, vaginal ring, implants) 1
• The patient should use non-hormonal contraceptive methods exclusively 1

When Extended Anticoagulation Would Be Indicated

Extended therapy is NOT indicated in this case, but would be considered if:

• The DVT had been unprovoked (no identifiable risk factors), which carries >5% annual recurrence risk 3
• The patient had recurrent unprovoked VTE, which carries 10-15% annual recurrence risk 2
• There were persistent risk factors such as active cancer or antiphospholipid syndrome 3, 6
• The DVT had been proximal (popliteal or above) rather than calf-confined 3

Post-Discontinuation Monitoring

No routine anticoagulation monitoring is needed after stopping, but the patient should:

• Seek immediate medical attention if symptoms of recurrent DVT develop (leg swelling, pain, warmth, redness) 7
• Seek immediate medical attention if symptoms of PE develop (chest pain, shortness of breath, hemoptysis) 7
• Avoid prolonged immobility during future travel by using frequent ambulation and hydration 1
• Consider mechanical prophylaxis (compression stockings) during high-risk situations like long flights 2

Common Pitfalls to Avoid

Do not:

• Continue anticoagulation beyond 6 months for provoked calf DVT—this only increases bleeding risk without reducing recurrence risk 3, 2
• Switch to aspirin for secondary prevention—this is only indicated for unprovoked proximal DVT/PE when anticoagulation is stopped 3
• Consider resuming any form of hormonal contraception in the future, even transdermal formulations 1, 4
• Perform routine thrombophilia testing unless there is family history of VTE or other concerning features suggesting inherited thrombophilia 1