Why should Eliquis (apixaban) be discontinued in a patient with atrial fibrillation and a history of multiple deep‑vein thromboses?

Why Discontinue Eliquis in a Patient with AFib and Multiple DVTs?

Eliquis should NOT be routinely discontinued in a patient with atrial fibrillation and a history of multiple DVTs—in fact, premature discontinuation significantly increases the risk of life-threatening thrombotic events including stroke and recurrent venous thromboembolism. 1

Critical FDA Black Box Warning

The FDA has issued a black box warning specifically addressing this scenario: premature discontinuation of Eliquis in the absence of adequate alternative anticoagulation increases the risk of thrombotic events. 1 An increased rate of stroke was observed during the transition from apixaban to warfarin in clinical trials of atrial fibrillation patients. 1

When Discontinuation IS Appropriate

Eliquis should only be discontinued in specific, well-defined circumstances 2, 1:

Pathological Bleeding

• Active major bleeding requiring urgent hemostasis 2, 1
• Life-threatening hemorrhage where bleeding risk outweighs thrombotic risk 2
• Intracranial hemorrhage with high-risk features for recurrence 3

Planned Surgical/Invasive Procedures

• Moderate-to-high bleeding risk procedures: discontinue at least 48 hours prior 1
• Low bleeding risk procedures: discontinue at least 24 hours prior 1
• Timing may need extension based on renal function (CrCl <50 mL/min requires longer interruption) 3

Completion of Therapy Course

• Only after completing the full recommended treatment duration for the indication 1
• For DVT/PE treatment: minimum 6 months before considering dose reduction to 2.5 mg twice daily for extended prophylaxis 1

The High-Risk Patient Profile

Your patient with AFib AND multiple DVTs has dual indications for anticoagulation, making discontinuation particularly dangerous. 1 This patient faces:

• Stroke risk from atrial fibrillation (assess CHA₂DS₂-VASc score) 3
• Recurrent VTE risk from multiple prior DVTs 1
• Compounded thrombotic risk if anticoagulation is stopped 4

In the ARISTOTLE trial, patients who prematurely discontinued apixaban had a 30-day cumulative incidence of thromboembolism of 2.6% and all-cause death of 5.8%. 4

If Discontinuation is Absolutely Required

If Eliquis must be stopped for reasons other than pathological bleeding or completion of therapy, you MUST provide coverage with another anticoagulant. 1 The approach depends on the clinical scenario 2, 1:

For Major Bleeding

• Discontinue immediately 2
• Consider reversal with andexanet alfa (specific reversal agent for apixaban) 2
• If andexanet unavailable, use 4-factor prothrombin complex concentrate 2
• Plan to restart anticoagulation as soon as hemostasis is achieved 2

For Elective Procedures

• Time discontinuation based on procedure bleeding risk and renal function 3, 1
• Bridging with LMWH is NOT generally required 1, 5
• Resume Eliquis when adequate hemostasis is established 1

Switching to Another Anticoagulant

• Discontinue Eliquis and begin the new anticoagulant at the time of the next scheduled Eliquis dose 1
• No gap in anticoagulation coverage 1

Common Pitfalls to Avoid

Do not discontinue based on bleeding fears alone without active bleeding. 2 Apixaban has demonstrated lower major bleeding rates (2.13% per year) compared to warfarin (3.36% per year) in the ARISTOTLE trial, with particularly favorable intracranial hemorrhage rates (0.33% vs 0.80%). 3

Do not stop anticoagulation during the transition period between agents. 1 The increased stroke rate observed during ARISTOTLE when transitioning from apixaban to warfarin highlights this danger. 1

Do not assume the patient can safely go without anticoagulation "for a few days." 1, 4 The pharmacodynamic effect of apixaban persists for at least 24 hours (approximately two half-lives), but thrombotic risk begins immediately upon discontinuation. 1

The Bottom Line for Your Patient

A patient with both AFib and multiple DVTs has compelling, ongoing indications for anticoagulation that typically persist lifelong. 3, 1 Eliquis at the appropriate dose (5 mg twice daily for most patients, or 2.5 mg twice daily if meeting dose-reduction criteria) should be continued indefinitely unless active pathological bleeding occurs or a high-risk procedure necessitates temporary interruption with a clear plan for resumption. 3, 1