What is the appropriate apixaban (Eliquis) regimen for a patient with a newly diagnosed non‑occlusive deep vein thrombosis in the emergency department?

Apixaban Management for Newly Discovered Non-Occlusive DVT in the Emergency Department

For a patient with newly diagnosed non-occlusive DVT in the ED, initiate apixaban at 10 mg orally twice daily for the first 7 days, then reduce to 5 mg orally twice daily for continued treatment—no parenteral anticoagulation is required before starting apixaban. 1, 2

Initial Loading Dose Regimen

• Start with 10 mg orally twice daily for exactly 7 days as the loading dose to achieve rapid therapeutic anticoagulation 1, 3, 2
• This loading dose can be initiated immediately in the ED without any preceding parenteral anticoagulation (no enoxaparin or heparin bridge needed) 1, 3, 4
• The first 10 mg dose should be given as soon as the diagnosis is confirmed and bleeding risk is assessed 2, 4

Maintenance Phase Dosing

• After completing 7 days at 10 mg twice daily, transition to 5 mg orally twice daily for the maintenance phase 1, 3, 2
• Continue this 5 mg twice daily dose for a minimum of 3 months for provoked DVT, or longer for unprovoked DVT or ongoing risk factors 3, 4
• The AMPLIFY trial demonstrated this regimen is non-inferior to conventional enoxaparin/warfarin therapy with significantly lower major bleeding rates (0.6% vs 1.8%) 3, 4

Critical Dosing Considerations

Renal Function Assessment

• Check creatinine clearance before initiating therapy—apixaban should be avoided in severe renal impairment (CrCl <15 mL/min) 3, 2
• Use caution with CrCl <25 mL/min, though no specific dose adjustment is required for the VTE treatment regimen 3, 2

Special Populations Requiring Standard Dosing

• Do NOT reduce the initial 10 mg twice daily dose even in elderly patients (≥80 years), low body weight (≤60 kg), or elevated creatinine (≥1.5 mg/dL) when treating acute VTE 2, 5
• The dose reduction criteria (2.5 mg twice daily) apply only to atrial fibrillation stroke prevention, not to acute VTE treatment 2, 5

Cancer-Associated DVT Considerations

• For patients with active cancer and DVT, apixaban is a reasonable alternative to LMWH, though LMWH remains preferred by some guidelines 1
• Use the same dosing regimen (10 mg twice daily for 7 days, then 5 mg twice daily) in cancer patients 1, 4
• Exercise caution in patients with luminal GI cancers due to increased bleeding risk, particularly with esophageal and gastroesophageal junction cancers 1

Extended Treatment Beyond 6 Months

• After completing at least 6 months of treatment, consider reducing to 2.5 mg orally twice daily for extended secondary prevention if continued anticoagulation is indicated 1, 3, 2
• This reduced dose minimizes bleeding risk while maintaining efficacy for preventing recurrent DVT 3, 2

Common Pitfalls to Avoid

• Do not use parenteral anticoagulation before starting apixaban—unlike dabigatran or edoxaban, apixaban does not require a heparin lead-in 1, 4
• Do not confuse atrial fibrillation dosing with VTE treatment dosing—the 2.5 mg twice daily dose is NOT appropriate for acute VTE treatment 2, 5
• Do not skip the 7-day loading phase—jumping directly to 5 mg twice daily provides inadequate initial anticoagulation 2, 4
• Avoid apixaban in patients requiring neuraxial anesthesia or spinal puncture within 24-48 hours due to risk of spinal/epidural hematoma 1, 2

Monitoring and Follow-Up

• No routine laboratory monitoring of anticoagulation effect is required 4
• Reassess renal function if clinical status changes, as deteriorating kidney function may necessitate dose adjustment or drug discontinuation 1, 3
• Evaluate for bleeding complications and VTE recurrence at regular intervals 4