Restarting Apixaban After Medication Error and 14-Day Gap
Start the patient directly at the maintenance dose of 5 mg twice daily without repeating the loading dose. 1
Rationale for Maintenance Dosing
The loading dose of apixaban 10 mg BID is specifically designed to rapidly achieve therapeutic anticoagulation during the initial 7 days of acute VTE treatment when the clot is fresh and most vulnerable to extension. 2, 3 After this initial treatment phase is completed, the therapeutic goal shifts from active treatment of the acute thrombosis to secondary prevention of recurrence. 4, 5
Key Clinical Considerations:
The acute treatment phase was already completed: Your patient received the full 7-day loading dose regimen (10 mg BID), which adequately treated the initial thrombotic event. 3, 1
The 14-day gap does not reset the treatment clock: The concept of "active treatment" for VTE is completed within approximately 3 months, with the first 7 days being the most critical period for treating the acute clot. 4, 5 The medication error created a gap in secondary prevention, not a failure to complete initial treatment.
No evidence supports re-loading after treatment gaps: Guidelines for restarting anticoagulation after interruptions (including for bleeding or procedures) consistently recommend resuming at the maintenance dose once hemostasis is achieved or the indication for interruption resolves. 6
Specific Dosing Instructions
Resume apixaban 5 mg orally twice daily immediately. 1 This is the FDA-approved maintenance dose after completing the 7-day loading phase for DVT/PE treatment. 1
Important Caveats:
Do not use bridging therapy: There is no indication for parenteral anticoagulation (heparin or LMWH) when restarting a DOAC like apixaban after an interruption. 6
Assess for dose reduction criteria: Verify the patient does NOT require the 2.5 mg BID dose, which is only indicated for extended-phase therapy (after at least 6 months of treatment) or for specific patient characteristics in atrial fibrillation. 2, 3, 1
Evaluate thrombotic risk: The 14-day gap places this patient at increased risk for recurrent VTE, particularly if the original event was unprovoked. 7, 5 VTE within 3 months of anticoagulation interruption is considered high thrombotic risk. 6
Clinical Pitfalls to Avoid
Do not repeat the 10 mg BID loading dose: This would provide supratherapeutic anticoagulation without additional benefit and increase bleeding risk unnecessarily. 1
Do not delay restarting: Each day without anticoagulation increases thrombotic risk, especially given the recent VTE history. 6, 7
Do not use prophylactic dosing (2.5 mg BID): This lower dose is insufficient for treatment of established VTE and should only be used for extended-phase therapy after completing at least 6 months of full-dose treatment. 3, 1
Duration of Continued Therapy
The patient should continue apixaban 5 mg BID to complete a minimum of 3 months total treatment from the original VTE diagnosis. 3, 5 After 3 months, reassess whether to continue indefinitely based on whether the VTE was provoked or unprovoked, bleeding risk, and patient preference. 3, 5