From the Guidelines
For a patient with new onset DVT in the brachial vein, direct oral anticoagulant therapy with apixaban (Eliquis) can be initiated without prior heparin therapy, as supported by the American Society of Hematology 2020 guidelines 1. The recommended dosing for apixaban is 10 mg twice daily for the first 7 days, followed by 5 mg twice daily for at least 3 months. This approach is supported by clinical evidence showing that direct oral anticoagulants are effective and safe for treating upper extremity DVT. When starting apixaban, ensure the patient has adequate renal function (reduce dose to 2.5 mg twice daily for patients with at least two of the following: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL) as suggested by the antithrombotic therapy for VTE disease: CHEST guideline and expert panel report 1. Some key points to consider when initiating apixaban therapy include:
- Patients should take apixaban with food and maintain consistent timing of doses
- The rationale for using apixaban directly is that it provides rapid anticoagulation (peak effect within 3-4 hours) and has a predictable anticoagulant response, eliminating the need for bridging with heparin
- Additionally, it offers the convenience of fixed dosing without routine monitoring requirements, potentially improving patient adherence and quality of life compared to parenteral therapy. It's worth noting that the choice of long-term anticoagulant therapy should be individualized, taking into account the patient's risk of recurrent VTE and anticoagulant-related bleeding, as well as their preferences and values 1.
From the FDA Drug Label
1.3 Treatment of Deep Vein Thrombosis Apixaban tablets are indicated for the treatment of DVT.
2.4 Converting from or to apixaban If anticoagulation with apixaban is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant
For a patient with new onset DVT in the brachial vein, heparin is typically needed initially for the treatment of DVT, and then apixaban (Eliquis) can be started. The FDA label does not provide direct guidance on the use of apixaban as the initial treatment for DVT without prior anticoagulation with heparin. Therefore, it is recommended to start with heparin and then transition to apixaban, as the label suggests considering coverage with another anticoagulant when discontinuing apixaban 2.
From the Research
Treatment Options for DVT in Brachial Vein
- For a patient with new onset DVT in the brachial vein, anticoagulation is indicated to control symptoms, prevent progression, and reduce the risk of post-thrombotic syndrome and pulmonary embolism 3.
- The treatment may consist of a parenteral anticoagulant overlapped by warfarin or followed by a direct oral anticoagulant (DOAC), or of a DOAC without initial parenteral therapy 3.
- Direct oral anticoagulants (DOACs) such as apixaban or rivaroxaban are preferred for the treatment of DVT because they are at least as effective, safer, and more convenient than warfarin 3, 4.
- A study found that treatment of upper extremity DVT with apixaban or rivaroxaban appears to be as safe and effective as low molecular weight heparin (LMWH)/warfarin 5.
Use of Heparin and Eliquis
- Heparin may be used as an initial treatment for DVT, but it is often overlapped by warfarin or followed by a DOAC 3, 6.
- Eliquis (apixaban) is a DOAC that can be used for the treatment of DVT, and it has been shown to be effective and safe for this indication 4, 5.
- The decision to use heparin or Eliquis (apixaban) should be based on the individual patient's characteristics, such as renal function, liver function, and bleeding risk 3, 7.