A patient with an acute proximal deep‑vein thrombosis in the superficial femoral vein, prescribed Eliquis (apixaban) 2.5 mg twice daily but likely non‑adherent and wanting discharge, what is the best anticoagulation treatment plan?

Critical Issue: Incorrect Apixaban Dosing and Non-Adherence

Your patient is on a dangerously inadequate dose of apixaban (2.5 mg BID) for acute proximal DVT treatment, and suspected non-adherence makes discharge unsafe without immediate intervention. 1

Immediate Corrective Action Required

The correct apixaban dosing for acute DVT treatment is 10 mg orally twice daily for the first 7 days, then 5 mg twice daily thereafter—not 2.5 mg BID. 1, 2 The 2.5 mg BID dose is reserved only for:

• Extended-phase anticoagulation (after completing at least 6 months of full-dose treatment) 3, 1
• DVT prophylaxis after hip/knee replacement surgery 1

Your patient requires immediate dose correction to therapeutic levels to prevent potentially fatal pulmonary embolism or clot extension. 2

Addressing Non-Adherence Before Discharge

If Patient Refuses Proper Anticoagulation

Do not discharge this patient if she refuses therapeutic anticoagulation—proximal DVT carries significant mortality risk from pulmonary embolism. 2 The superficial femoral vein (despite its name) is a deep vein, and thrombosis at this location adjacent to the greater saphenous junction represents high-risk proximal DVT requiring full anticoagulation. 2

Strategies to Improve Adherence

Consider switching to once-daily rivaroxaban (15 mg BID for 21 days, then 20 mg once daily) if twice-daily dosing is a barrier to adherence. 2 This regimen may improve compliance compared to twice-daily apixaban. 3

If oral medication adherence is unreliable, initiate low-molecular-weight heparin (LMWH) such as enoxaparin 1 mg/kg subcutaneously twice daily or 1.5 mg/kg once daily, which can be administered by visiting nurses or family members. 2 LMWH is strongly recommended over unfractionated heparin for acute DVT. 3

Arrange immediate outpatient follow-up within 48-72 hours with anticoagulation clinic or primary care to verify medication acquisition and adherence. 2

Treatment Algorithm for This Patient

Option 1: Correct the Apixaban Dose (If Adherence Can Be Assured)

• Restart apixaban at 10 mg orally twice daily immediately 1, 2
• Continue 10 mg BID for 7 days, then reduce to 5 mg BID 1, 2
• Minimum treatment duration: 3 months for provoked DVT; extended therapy for unprovoked DVT 3
• Do not discharge until you witness the patient taking the first correct dose and confirm she has obtained the medication 2

Option 2: Switch to Once-Daily DOAC (If Twice-Daily Dosing Is the Barrier)

• Rivaroxaban 15 mg orally twice daily for 21 days, then 20 mg once daily 2
• This eliminates the need for twice-daily dosing after the initial 3 weeks 3

Option 3: LMWH Bridge (If Oral Adherence Cannot Be Assured)

• Enoxaparin 1 mg/kg subcutaneously twice daily or 1.5 mg/kg once daily 2
• Arrange home health nursing for administration if patient/family cannot inject 2
• Transition to oral anticoagulation only after adherence barriers are addressed 2

Option 4: Brief Hospitalization (If All Outpatient Options Fail)

• Admit for 24-48 hours to initiate therapeutic anticoagulation and arrange close outpatient follow-up 2
• Use this time to educate patient on DVT risks and ensure medication access 2

Critical Pitfalls to Avoid

Never discharge a patient with acute proximal DVT on subtherapeutic anticoagulation—this is a medical-legal and patient safety crisis. 2 The 2.5 mg BID dose provides only prophylactic-level anticoagulation, leaving her at high risk for:

• Pulmonary embolism (potentially fatal) 2
• Clot extension 2
• Post-thrombotic syndrome 3

Do not place an IVC filter in this patient—filters are reserved only for absolute contraindications to anticoagulation or recurrent PE despite adequate therapy. 2 Suspected non-adherence is not an indication for IVC filter placement. 2

Do not use aspirin as an alternative to anticoagulation for acute DVT—aspirin is vastly inferior and only considered after completing full anticoagulation when extended therapy is declined. 3

Renal and Hepatic Considerations

Apixaban is the preferred DOAC if creatinine clearance is <30 mL/min, as only 25% is renally cleared (compared to 80% for dabigatran). 3 Verify renal function before finalizing anticoagulant choice. 3

Avoid all DOACs if severe hepatic disease with coagulopathy is present. 3

Documentation and Follow-Up

Document the dosing error, your correction, patient education provided, and adherence plan in the medical record. 2 Schedule mandatory follow-up within 1 week to reassess adherence and clinical status. 2

If the patient leaves against medical advice without accepting therapeutic anticoagulation, document this thoroughly and notify her primary care physician immediately. 2