How should a 69-year-old woman with a catheter-related brachial deep-vein thrombosis, who ran out of apixaban (Eliquis) 2.5 mg twice daily after one month and cannot afford it, be managed?

Management of Catheter-Related Brachial DVT When Apixaban Is Unaffordable

Switch immediately to low-molecular-weight heparin (LMWH) such as enoxaparin 1 mg/kg subcutaneously every 12 hours, or transition to warfarin with LMWH bridging until INR reaches 2-3, as these are the guideline-recommended alternatives when direct oral anticoagulants are unavailable or unaffordable. 1

Immediate Action Required

Resume anticoagulation urgently – this patient has already been off anticoagulation for an unknown period after running out of medication, which significantly increases her risk of recurrent thrombosis and pulmonary embolism. 1

Cost-Effective Anticoagulation Options

First-Line Alternative: Low-Molecular-Weight Heparin (LMWH)

• LMWH alone (enoxaparin 1 mg/kg subcutaneously every 12 hours OR 1.5 mg/kg once daily) is the preferred alternative for catheter-related thrombosis when DOACs are unavailable, as it is more effective than warfarin at preventing thrombotic recurrences in this population. 1

• Continue LMWH for a minimum of 3 months if the catheter has been removed. 1

• If the catheter remains in place, continue therapeutic anticoagulation for at least 3 months, then transition to prophylactic-dose anticoagulation for as long as the catheter is present. 1, 2

Second-Line Alternative: Warfarin

• LMWH followed by warfarin is an acceptable alternative, though warfarin requires INR monitoring (target 2-3) and has more drug-food interactions. 1

• Begin warfarin simultaneously with LMWH, continue LMWH until INR is therapeutic (≥2.0) for at least 24 hours, then discontinue LMWH. 1

• Continue warfarin for a minimum of 3-6 months. 1

Catheter Management Decision

Remove the Catheter If:

• Central venous access is no longer necessary 1, 2
• The catheter is non-functioning or defective 1, 2
• Line-related sepsis is suspected or documented 1, 2
• Long-term anticoagulation is contraindicated 1, 2

Retain the Catheter If:

• Central access remains medically necessary 1, 2
• The catheter is functioning properly 1, 2
• No infection is present 1, 2
• The patient can tolerate anticoagulation 1, 2

Critical Safety Consideration

Never remove a thrombosed catheter without at least 3-5 days of prior anticoagulation, as this significantly increases the risk of pulmonary embolism from clot embolization. 1, 2

Duration of Anticoagulation

• Minimum 3 months of therapeutic anticoagulation is required for catheter-related DVT. 1

• If the catheter was removed after completing 3 months of therapy, anticoagulation can be stopped. 1

• If the catheter remains in place, continue prophylactic-dose anticoagulation (enoxaparin 40 mg daily or warfarin with INR 1.5-2.0) until catheter removal. 1, 2

Cost-Reduction Strategies

Patient Assistance Programs

• Contact the manufacturer of apixaban (Bristol-Myers Squibb) for patient assistance programs that may provide medication at reduced cost or free for qualifying patients.

• Many pharmaceutical companies offer copay cards or financial assistance for patients without adequate insurance coverage.

Generic Alternatives

• Warfarin is available as a low-cost generic and requires only periodic INR monitoring (typically every 2-4 weeks once stable). 1

• Generic enoxaparin is available and may be more affordable than brand-name LMWH, though still more expensive than warfarin.

Insurance and Formulary Review

• Review the patient's insurance formulary – some plans may cover other DOACs (rivaroxaban, edoxaban) at lower copays than apixaban.

• Request a formulary exception or prior authorization from insurance if apixaban is not covered but is medically preferred.

Common Pitfalls to Avoid

• Do not restart apixaban at the loading dose (10 mg twice daily) – since she already completed one month of therapy, if apixaban becomes available again, resume at the maintenance dose of 5 mg twice daily. 3, 4

• Do not use aspirin as a substitute for anticoagulation – aspirin is much less effective at preventing recurrent VTE and is only considered when patients refuse or cannot tolerate any anticoagulant. 1

• Do not use thrombolytic therapy – this is not recommended as first-line treatment for catheter-related thrombosis due to increased bleeding risk. 1, 2

• Avoid NSAIDs and antiplatelet agents while on anticoagulation, as these substantially increase bleeding risk. 3

Monitoring Requirements

For LMWH:

• Baseline complete blood count, platelet count, renal function, and hepatic function 5
• Anti-Xa levels are not routinely required unless the patient has severe renal impairment (CrCl <30 mL/min) or extreme body weight 5
• Monitor for signs of bleeding

For Warfarin:

• INR monitoring every 2-3 days initially until therapeutic, then weekly until stable, then every 2-4 weeks 1
• Target INR 2-3 for VTE treatment 1
• Monitor for drug-food interactions and dose adjustments

Special Considerations for This Patient

• At 69 years old, this patient does not meet criteria for dose reduction of apixaban (which requires age ≥80 years plus other factors), so if apixaban becomes available again, the standard 5 mg twice daily maintenance dose is appropriate. 4

• Assess renal function – if creatinine clearance is <30 mL/min, LMWH requires dose adjustment or anti-Xa monitoring, and warfarin may be preferred. 5, 4

• Catheter-related thrombosis has a low risk of recurrence and post-thrombotic syndrome, supporting conservative treatment with anticoagulation alone rather than more aggressive interventions. 1