Preventing Clots in Patients with Cancer: Low-Dose Apixaban Is Effective and Safer!

An Often Overlooked Problem in Cancer

Venous blood clots, or venous thromboembolism (VTE), can recur in patients with cancer even after treatment and are among the leading causes of death apart from cancer itself. However, prolonged anticoagulant use also carries serious bleeding risks. The appropriate dose and duration of anticoagulation therefore remained important questions for oncology and cardiology. Seeking to fill this gap, the API-CAT studyfound that low-dose apixaban (Eliquis), compared with standard dosing, is both effective and safer , making the study a potential catalyst for guideline changes.

API-CAT findings were presented at the 2025 American College of Cardiology (ACC) Scientific Session and simultaneously published online on March 29, 2025, in New England Journal of Medicine (NEJM) .

• Related topic: Which Anticoagulant Is More Effective at Reducing Clot Risk in Cancer?

API-CAT: Design and Participant Profile

1766 Patients with Cancer from 11 Countries

API-CAT is a large randomized clinical trial spanning 11 countries and involving 1766 patients with active cancer . Among participants:

• 65.8% had metastatic disease.
• 81.2% were receiving active cancer treatment.
• The most common cancers were breast (22.7%), colorectal (15.2%), gynecological (12.1%), and lung (11.3%).

All patients had previously experienced a proximal deep vein thrombosis or pulmonary embolism and had received at least 6 months of anticoagulation.

Reduced Dose or Full Dose?

Patients were randomized into two groups:

• Reduced-dose apixaban (2.5 mg, 2 times daily)
• Full-dose apixaban (5 mg, 2 times daily)

Follow-up: 12 months.

Primary Aim:

To assess whether reduced dosing maintained effectiveness against recurrent VTE compared with full dosing, while causing fewer adverse reactions .

Findings: The Numbers

Recurrent VTE:

• Reduced-dose group: 2.1% (18 patients)
• Full-dose group: 2.8% (24 patients)
• Statistical analysis: Noninferiority was demonstrated (meaning the reduced dose was at least as effective as the full dose)
  Adjusted subhazard ratio (aSHR): 0.76; 95% CI: 0.41 – 1.41; P = 0.001

Clinically Relevant Bleeding:

• Reduced dose: 12.1% (102 patients)
• Full dose: 15.6% (136 patients)
• Bleeding risk was significantly lower
  aSHR: 0.75; 95% CI: 0.58 – 0.97; P = 0.03

Mortality:

• Reduced dose: 17.7%
• Full dose: 19.6%
• No significant difference.

Interpretation

“Guidelines Will Change”

Lead investigator Dr. Isabelle Mahé expressed confidence that treatment practice would change, stating, “Reduced-dose apixaban should now be preferred for VTE prevention in patients with cancer.”

Major News for Oncology and Cardiology

For the first time, we clearly demonstrate in such a large population that reduced dosing is sufficient. For millions receiving cancer treatment, this means a safer future with less bleeding risk .

VTE: A Silent Problem in Patients with Cancer

In patients with cancer, VTE is the second most common cause of death after cancer itself. Patients now survive for months and years, making recurrent clot risk a chronic concern.

Just as atherosclerosis requires chronic treatment, VTE is a long-term disease and must not be dismissed as a one-time event.

What Will Change in Clinical Practice?

• Apixaban 2.5 mg/day x 2 may become the preferred new standard after 6 months in patients with cancer.
• Reduced dosing prevents VTE while reducing bleeding that compromises quality of life.
• The shared decision-making process with patients will strengthen because clear adverse-reaction data are now available.

The study's value lies in clinical outcomes and patient experiences, making physician–patient discussions more meaningful.

Conclusion: Less Medicine, Greater Safety

API-CAT provides strong evidence, particularly for patients with cancer at long-term VTE risk, that reduced-dose apixaban is both safe and effective .

These findings open the door to changes in clinical practice and the opportunity to offer safer treatment that improves quality of life.