What is the management plan for a patient on Eliquis (apixaban), Brilinta (ticagrelor), and aspirin for conditions like atrial fibrillation or acute coronary syndrome?

From the Guidelines

The management of a patient on triple antithrombotic therapy with Eliquis (apixaban), Brilinta (ticagrelor), and aspirin requires careful monitoring and typically time-limited use due to bleeding risks, with a recommended duration of 1-6 months depending on the patient's specific condition and bleeding risk. For patients with both atrial fibrillation and recent acute coronary syndrome or stent placement, consider transitioning to dual therapy (typically an anticoagulant plus a single antiplatelet) after the initial high-risk period, as supported by the 2021 ACC expert consensus decision pathway 1. Standard dosing includes apixaban 5mg twice daily (or 2.5mg twice daily for patients meeting dose reduction criteria), ticagrelor 90mg twice daily, and aspirin 81mg daily.

Key Considerations

• Regular monitoring should include complete blood counts, renal function, and clinical assessment for bleeding, as bleeding risks are significantly increased with triple antithrombotic therapy 1.
• Patients should be educated about bleeding signs and instructed to seek immediate medical attention for significant bleeding events.
• The decision to extend or shorten the duration of triple antithrombotic therapy should be based on the individual patient's thrombotic versus hemorrhagic risk profile, with consideration of factors such as the presence of atrial fibrillation, acute coronary syndrome, or stent placement, as well as the patient's bleeding risk factors.

Treatment Duration

• For patients at high ischemic/thrombotic risk and low bleeding risk, triple therapy may be continued for up to 1 month after PCI, as suggested by the 2018 North American expert consensus update 1.
• For patients at low ischemic/thrombotic risk or high bleeding risk, consider discontinuing aspirin and transitioning to dual therapy with an anticoagulant and a single antiplatelet agent after the initial high-risk period.
• The ultimate goal is to balance the need to prevent stroke in atrial fibrillation and stent thrombosis while minimizing the risk of bleeding complications, as emphasized by the 2021 ACC expert consensus decision pathway 1.

From the FDA Drug Label

7.3 Anticoagulants and Antiplatelet Agents Coadministration of antiplatelet agents, fibrinolytics, heparin, aspirin, and chronic NSAID use increases the risk of bleeding APPRAISE-2, a placebo-controlled clinical trial of apixaban in high-risk, post-acute coronary syndrome patients treated with aspirin or the combination of aspirin and clopidogrel, was terminated early due to a higher rate of bleeding with apixaban compared to placebo. In ARISTOTLE, concomitant use of aspirin increased the bleeding risk on apixaban from 1.8% per year to 3.4% per year and concomitant use of aspirin and warfarin increased the bleeding risk from 2.7% per year to 4.6% per year.

The management plan for a patient on Eliquis (apixaban), Brilinta (ticagrelor), and aspirin for conditions like atrial fibrillation or acute coronary syndrome should focus on bleeding risk management.

• Key considerations:
  • The patient is at an increased risk of bleeding due to the concomitant use of antiplatelet agents (aspirin and ticagrelor) and an anticoagulant (apixaban).
  • The risk of bleeding should be carefully weighed against the benefits of anticoagulation and antiplatelet therapy.
  • Regular monitoring of the patient's bleeding risk and adjustment of the treatment plan as needed is crucial.
  • Patients should be educated on the signs and symptoms of bleeding and the importance of seeking immediate medical attention if they occur.
  • The use of apixaban with aspirin and ticagrelor should be carefully managed, and the patient should be closely monitored for signs of bleeding 2.

From the Research

Management Plan for Patients on Eliquis, Brilinta, and Aspirin

The management plan for patients taking Eliquis (apixaban), Brilinta (ticagrelor), and aspirin for conditions like atrial fibrillation or acute coronary syndrome involves careful consideration of the benefits and risks of antithrombotic therapy.

• The combination of anticoagulant and antiplatelet therapy is more effective than antiplatelet therapy alone for the initial and long-term management of acute coronary syndromes, but it increases the risk of bleeding 3.
• Apixaban has been shown to significantly reduce the risk of total bleeding compared to vitamin K antagonists (VKA) in patients with atrial fibrillation and recent acute coronary syndrome or percutaneous coronary intervention 4.
• Aspirin has been found to double the total bleeding risk compared to placebo without a significant change in total ischemic events in patients with atrial fibrillation and recent acute coronary syndrome or percutaneous coronary intervention 4.

Antithrombotic Regimens

The choice of antithrombotic regimen depends on various factors, including the patient's risk of bleeding and ischemic events.

• The use of apixaban plus a P2Y12 inhibitor (e.g., clopidogrel) without aspirin is supported as the standard therapy for patients with atrial fibrillation and recent acute coronary syndrome or percutaneous coronary intervention 4, 5.
• Dabigatran dual therapy with ticagrelor or clopidogrel has been evaluated in patients with atrial fibrillation after percutaneous coronary intervention, and the results suggest that dabigatran dual therapy reduces the risk of major or clinically relevant non-major bleeding events compared to warfarin triple therapy 6.

Risk/Benefit Tradeoff

The risk/benefit tradeoff of antithrombotic therapy in patients with atrial fibrillation early and late after an acute coronary syndrome or percutaneous coronary intervention should be carefully considered.

• Apixaban has been shown to have a lower or similar risk of bleeding and ischemic outcomes compared to VKA from randomization to 30 days and from 30 days to 6 months 7.
• Aspirin has been found to cause more severe bleeding and fewer severe ischemic events than placebo from randomization to 30 days, but the risk of severe bleeding remains higher with aspirin than placebo from 30 days to 6 months, without a significant reduction in severe ischemic events 7.