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Provoked proximal deep-vein thrombosis after elective total hip replacement — MSRA MCQ

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HardHip and GroinProvoked proximal deep-vein thrombosis after elective total hip replacementMSRA

An 82-year-old woman is reviewed 12 days after an uncomplicated elective total hip replacement. She has been taking apixaban 2.5 mg twice daily as postoperative venous thromboembolism prophylaxis. She now has unilateral calf swelling and discomfort; same-day proximal leg vein ultrasound confirms a symptomatic femoral deep-vein thrombosis. She has no chest pain, breathlessness, wound bleeding or melaena. Her creatinine clearance is 42 mL/min, body weight is 54 kg, and liver function tests are normal. What is the most appropriate anticoagulant regimen?

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Correct answer: D — Replace prophylactic apixaban with apixaban 10 mg twice daily for 7 days, then apixaban 5 mg twice daily, with review of treatment duration at 3 months

This is an acute symptomatic proximal DVT despite appropriate postoperative prophylaxis. Apixaban 2.5 mg twice daily is the licensed prophylactic regimen after elective hip replacement, not a treatment dose for established VTE. Acute DVT requires apixaban 10 mg twice daily for 7 days followed by 5 mg twice daily. Her recent operation and temporary immobility are transient provoking factors, so treatment should be reviewed at 3 months; the SmPC states that short-duration treatment of at least 3 months is appropriate for VTE associated with transient risk factors. Her age, weight below 60 kg and renal function may prompt recollection of the atrial-fibrillation dose-reduction criteria, but these do not apply to VTE treatment. In mild-to-moderate renal impairment, no apixaban dose adjustment is required for DVT treatment. A continues an inadequate acute-VTE dose. C omits the required initial 7-day treatment phase. D uses the dose reserved for prevention of recurrent DVT/PE after completion of 6 months of therapeutic anticoagulation. E exposes her to concurrent anticoagulants without indication; apixaban does not require heparin lead-in for acute DVT treatment.

Reference: Eliquis 2.5 mg film-coated tablets Summary of Product Characteristics (accessed 16 August 2026) — https://www.medicines.org.uk/emc/product/4756/smpc Eliquis 2.5 mg film-coated tablets Summary of Product Characteristics (accessed 16 August 2026) — https://www.medicines.org.uk/emc/product/4756/smpc Eliquis 2.5 mg film-coated tablets Summary of Product Characteristics (accessed 16 August 2026) — https://www.medicines.org.uk/emc/product/4756/smpc