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Apixaban

Class
Anticoagulants
Subclass
Direct factor Xa inhibitors
Generic name
Apixaban
Brand names
Eliquis®
Common formulations
Film-coated tablet
Dosage and administration
Adults patients
Treatment
DVT
•
Start at: 10 mg PO BID for 7 days
•
Maintenance: 5 mg PO BID
PE
•
Start at: 10 mg PO BID for 7 days
•
Maintenance: 5 mg PO BID
Cancer-associated thrombosis • Off-label
•
Start at: 10 mg PO BID for 7 days
•
Maintenance: 5 mg PO BID for 6 months
Heparin-induced thrombocytopenia • Acute, without thrombosis • Off-label
•
5 mg PO BID until platelet count recovery
Heparin-induced thrombocytopenia • Acute, with thrombosis • Off-label
•
Start at: 10 mg PO BID for 7 days
•
Maintenance: 5 mg PO BID
Prevention
Arterial thromboembolism in patients with NVAF
•
5 mg PO BID
Reduce to 2.5 mg BID in patients with at least 2 of the following: age ≥ 80 years, body weight ≤ 60 kg, serum creatinine ≥ 133 mcmol/L ( ≥ 1.5 mg/dL).
DVT, after hip replacement
•
2.5 mg PO BID for 35 days
First dose taken 12-24 hours after surgery.
DVT, during knee replacement
•
2.5 mg PO BID for 12 days
First dose taken 12-24 hours after surgery.
Cancer-associated thrombosis • High-to-intermediate-risk • Off-label
•
2.5 mg PO BID for 6 months
Secondary prevention
DVT
•
2.5 mg PO BID for 6 months
Started after at least 6 months of treatment for DVT.
PE
•
2.5 mg PO BID for 6 months
Started after at least 6 months of treatment for PE.
Indications for use
Labeled indications
Adults
•
Treatment of DVT
•
Treatment of PE
•
Prevention of arterial thromboembolism in patients with NVAF
•
Prevention of DVT, after hip replacement
•
Prevention of DVT, in patients undergoing knee replacement
•
Secondary prevention of DVT
•
Secondary prevention of PE
Off-label indications
Adults
•
Treatment of cancer-associated thrombosis
•
Treatment of heparin-induced thrombocytopenia (acute, with thrombosis)
•
Treatment of heparin-induced thrombocytopenia (acute, without thrombosis)
•
Prevention of cancer-associated thrombosis (high-to-intermediate-risk)
Safety risks
Boxed warnings
Epidural hematoma, spinal hematoma
•
Do not use in patients undergoing neuraxial anesthesia or spinal puncture. Delay the administration of apixaban for 48 hours if a traumatic epidural or spinal puncture occurs. Do not remove indwelling epidural or intrathecal catheters < 24 hours after the last administration of apixaban. Administer the next dose > 5 hours after the removal of the catheter.
Thrombosis
•
Maintain a high level of suspicion in patients discontinuing apixaban prematurely.
Contraindications
Hypersensitivity to apixaban or its components
Active pathological bleeding
Acute PE
•
Do not use apixaban instead of UFH for initial management of patients with PE presenting with hemodynamic instability or who may receive thrombolysis or pulmonary embolectomy.
Prosthetic heart valves
•
Do not use in patients with prosthetic heart valves, as efficacy and safety have not been demonstrated.
Triple-positive antiphospholipid syndrome
Warnings and precautions
AIS
•
Use extreme caution in patients with AF transitioning from apixaban to warfarin.
Bleeding
•
Use caution in patients taking other drugs affecting hemostasis, including antiplatelet, anticoagulant, or thrombolytic agents, SSRIs, SNRIs, and NSAIDs.
Increased serum apixaban levels
•
Use caution in patients taking P-glycoprotein or potent CYP3A4 inhibitors (such as ketoconazole, itraconazole, or ritonavir). Reduce the dose of apixaban from 5-10 mg BID by 50%. Do not use P-glycoprotein or potent CYP3A4 inhibitors in patients receiving 2.5 mg BID of apixaban.
Specific populations
Renal impairment
eGFR 0-90 mL/min/1.73 m²
•
For atrial fibrillation, reduce to 2.5 mg PO BID if serum creatinine is ≥ 133 mcmol/L (≥ 1.5 mg/dL) with weight ≤ 60 kg or age ≥ 80 years. No dose adjustment is required for other indications. Limited clinical experience n patients with eGFR < 15 mL/min/1.73 m².
Renal replacement therapy
Continuous renal replacement
•
Use with caution. Titrate with caution.
Intermittent hemodialysis
•
Use with caution. Titrate with caution.
Peritoneal dialysis
•
Use with caution. Titrate with caution.
Hepatic impairment
Child-Pugh A (mild)
•
Use acceptable. No dose adjustment required.
Child-Pugh B (moderate)
•
No guidance available.
Child-Pugh C (severe)
•
Do not use.
Pregnancy and breastfeeding
Pregnancy
All trimesters • Australia Category: C
•
Use only if benefits outweigh potential risks. Evidence of fetal harm in humans. Monitor pregnant women for bleeding. Monitor neonates for bleeding. Recognize that apixaban may increase the risk of bleeding during pregnancy and delivery, as well as the risk of bleeding in the fetus or neonate.
Breastfeeding
Do not use during breastfeeding.
•
Consider alternative agents that may be safer.
Unknown drug levels in breastfed infants.
Adverse reactions
Common 1-10%
•
Anemia, bleeding, menorrhagia, gingival bleeding, hematuria, nosebleed
Uncommon < 1%
•
Anaphylaxis, ↓ platelet count, gastrointestinal bleeding, hypotension, intracranial hemorrhage, ↑ liver enzymes, ↑ serum ALP, ↑ serum TBIL, injection site hematoma, hematemesis, hematochezia, hemoptysis, melena, rectal bleeding, skin rash, syncope, vaginal bleeding, subconjunctival hemorrhage, retinal hemorrhage
Unknown frequency
•
Hair loss, spinal hematoma, epidural hematoma
Interactions
Drug(s)
Check Interactions
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