Management of Pulmonary Embolism with Eliquis

Introduction to Treatment Duration

The American College of Chest Physicians recommends that patients with unprovoked pulmonary embolism (PE) and low or moderate bleeding risk should continue anticoagulation indefinitely, with annual reassessment, rather than stopping at a fixed time point 1, 2.

For patients with provoked PE due to surgery, the American College of Chest Physicians recommends treating with anticoagulation for exactly 3 months, then stopping, as the annual recurrence risk is less than 1% after completing treatment, which is a Grade 1B recommendation 3, 2.
For patients with provoked PE due to a non-surgical transient risk factor, the standard treatment duration is 3 months 3, 2.
For women with hormone-associated PE, the guideline recommends discontinuing hormonal therapy before stopping anticoagulation 1, 2.
All patients with unprovoked PE require at least 3 months of anticoagulation, after which the decision to extend treatment depends on bleeding risk, with an annual recurrence risk exceeding 5% after stopping anticoagulation 3, 1.
For patients with unprovoked PE and low or moderate bleeding risk, extended anticoagulation is recommended over stopping at 3 months, with a Grade 2B recommendation 3, 1.
For patients with unprovoked PE and high bleeding risk, stopping anticoagulation at 3 months is recommended, with a Grade 1B recommendation 3, 1.

For patients with a second unprovoked PE, extended anticoagulation is strongly recommended, with a Grade 1B recommendation for low bleeding risk and Grade 2B for moderate bleeding risk 3, 1.
For patients with cancer-associated PE, extended anticoagulation is recommended regardless of bleeding risk, although low molecular weight heparin (LMWH) is preferred over direct oral anticoagulants (DOACs) for cancer-associated venous thromboembolism (VTE) 3, 4.

Annual reassessment is required for all patients on extended anticoagulation, including evaluation of bleeding risk factors, medication adherence, patient preference, drug tolerance, and hepatic and renal function 1, 2, 4.

The AMPLIFY trial demonstrated that apixaban was non-inferior to enoxaparin/warfarin for treating acute VTE, including PE, with significantly less major bleeding (0.6% vs 1.8%, P<0.001) 5.