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Patient Evidence Summary
Doctor, I have an unprovoked blood clot. Can I reduce the dose of apixaban or rivaroxaban after an initial 6 months of treatment?
In patients with unprovoked DVT or PE who have completed at least six months of treatment with a full-dose direct oral anticoagulant (DOAC), switching to a reduced-dose DOAC (either apixaban 2.5 mg twice a day, or rivaroxaban 10 mg once a day) provides excellent protection from recurrent clots, while also reducing the risk of bleeding. Always speak with your doctor before making any changes to your medications.
Study highlights
About 2 people out of 100 taking reduced-dose apixaban or rivaroxaban had a recurrent DVT or PE, which was similar to people who continued to take full-dose apixaban or rivaroxaban. People who took reduced-dose apixaban or rivaroxaban had a lower risk of bleeding than people who continued full-dose apixaban or rivaroxaban.
Understanding the problem
Patients with a history of an unprovoked blood clots benefit from taking blood thinners long-term to prevent recurrent blood clots. However, taking blood thinners also increases the risk of bleeding. Patients often ask if it they can take a lower dose of blood thinners after the initial treatment period to lower the risk of bleeding while still receiving protection from recurrent blood clots.
A previous study, AMPLIFY-EXTEND, showed that after 6 months of full-dose apixaban, people taking a reduced-dose of apixaban had a lower risk of recurrent DVT or PE than people who stopped taking apixaban. Another study called EINSTEIN-CHOICE found that after 6 months of full-dose rivaroxaban, people taking a reduced-dose of rivaroxaban had a lower risk of recurrent DVT or PE than people who switched to aspirin. However, these studies did not compare the reduced-doses of apixaban or rivaroxaban with continuing full-dose apixaban or full-dose rivaroxaban.
The researchers wanted to know if after taking full-dose apixaban or full-dose rivaroxaban for 6 months, a reduced-dose of apixaban or reduced-dose rivaroxaban would be as effective as continuing full-dose anticoagulation for preventing recurrent DVT or PE and have a lower risk of bleeding.
Who? The study included 2768 people (35% female, 41% had PE without a DVT) who had received 6-24 months of full-dose DOAC therapy, who were at high risk of a recurrent clot and therefore required long-term anticoagulation. People were excluded if they had active cancer in the last 6 months, severe liver or kidney disease, had another reason for anticoagulation (i.e. mechanical valves), or had a high bleeding risk.
What? The study compared reduced-dose apixaban or rivaroxaban versus full-dose apixaban or rivaroxaban.
Reduced-dose apixaban or rivaroxaban | vs | Full-dose apixaban or rivaroxaban |
|---|---|---|
Apixaban 2.5 mg twice a day or rivaroxaban 10 mg once daily | Apixaban 5 mg twice a day or rivaroxaban 20 mg once daily |
Reduced-dose apixaban or rivaroxaban vs full-dose apixaban or rivaroxaban in patients with unprovoked DVT or PE who had been treated with full-dose anticoagulants for at least 6 months
| Outcomes at 36 months | Rate of events with reduced-dose anticoagulant | Rate of events with full-dose anticoagulant | Results |
|---|---|---|---|
| Recurrent DVT or PE | 2 out of 100 people | 2 out of 100 people | People who took reduced-dose anticoagulants had a similar low rate of recurrent DVT or PE as people who continued full-dose anticoagulants. |
| Major or clinically relevant bleeding | 10 out of 100 people | 15 out of 100 people | People who took reduced-dose anticoagulants had a lower risk of major or clinically relevant bleeding compared to people who continued full-dose anticoagulants. |
This Evidence Summary is based on the following article:
Couturaud F, Schmidt J, Sanchez O. Extended treatment of venous thromboembolism with reduced-dose versus full-dose direct oral anticoagulants in patients at high risk of recurrence: a non-inferiority, multicentre, randomised, open-label, blinded endpoint trial. Lancet 2025; 405: 725–35.
Owen Litwin MD, MSc, FRCPC
Owen is completing a fellowship in General Internal Medicine at the University of Calgary. His current interests include advancing thrombosis medicine research and curriculum development/trainee evaluation.
Victoria David, MD MSc MEHP FRCPC
Dr. Victoria David is a hematologist and clinician educator specializing in thrombosis medicine. She is a Clinical Assistant Professor at the University of Calgary and a member of the Calgary thrombosis group where she provides care in the cancer-associated thrombosis clinic.
Beyond her clinical work, Dr. David is deeply committed to medical education. She holds a Master of Education in the Health Professions and a Clinician Educator Diploma from the Royal College of Physicians and Surgeons of Canada.
Published: Thursday, August 21, 2025
Please note that the information contained herein is not to be interpreted as an alternative to medical advice from a professional healthcare provider. If you have any questions about any medical matter, you should consult your professional healthcare providers, and should never delay seeking medical advice, disregard medical advice or discontinue medication based on information provided here.
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This Evidence Summary was printed from the CLOT+ website on 2025/12/05. To view other Evidence Summaries or to register to receive email notifications about new Evidence Summaries, please visit us at https://plus.mcmaster.ca/ClotPlus/Articles/EvidenceSummaries |
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, McMaster University