How to manage a patient on Plavix (clopidogrel) who requires Eliquis (apixaban) for a condition like atrial fibrillation with impaired renal function?

From the Guidelines

For patients with atrial fibrillation and impaired renal function who require both Plavix (clopidogrel) and Eliquis (apixaban), the recommended approach is to use the lowest effective dose of each medication and limit the duration of dual therapy when possible, as supported by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1.

Key Considerations

• For Eliquis, patients with impaired renal function (CrCl 15-29 mL/min) should receive a reduced dose of 2.5 mg twice daily, while those with better renal function typically receive 5 mg twice daily.
• Clopidogrel should be maintained at 75 mg daily.
• Regular monitoring of renal function, complete blood counts, and signs of bleeding is essential.

Management Strategy

• If the patient requires both medications due to recent coronary stenting and atrial fibrillation, consider limiting dual therapy to the minimum required time based on stent type (typically 1-6 months), then continuing only the anticoagulant for atrial fibrillation.
• For patients with severe renal impairment (CrCl <15 mL/min), Eliquis is generally not recommended, as stated in the guidelines 1.

Rationale

• The increased bleeding risk occurs because both medications affect hemostasis through different mechanisms - clopidogrel inhibits platelet aggregation while apixaban inhibits factor Xa in the coagulation cascade, creating a compounded effect on clotting.
• The guidelines emphasize the importance of evaluating renal function prior to initiation of direct thrombin or factor Xa inhibitors and re-evaluating when clinically indicated and at least annually 1.

From the FDA Drug Label

8.6 Renal Impairment Reduction of Risk of Stroke and Systemic Embolism in Patients with Nonvalvular Atrial Fibrillation The recommended dose is 2.5 mg twice daily in patients with at least two of the following characteristics [see Dosage and Administration (2.1)]: • age greater than or equal to 80 years • body weight less than or equal to 60 kg • serum creatinine greater than or equal to 1.5 mg/dL

The FDA drug label does not answer the question about Eliquis loading in a patient on Plavix with acute conditions or atrial fibrillation with impaired renal function.

From the Research

Managing Patients on Plavix with Acute Conditions

• When managing a patient on Plavix (clopidogrel) who requires Eliquis (apixaban) for a condition like atrial fibrillation with impaired renal function, several factors must be considered.
• The use of apixaban in patients with atrial fibrillation and impaired renal function has been studied in several trials 2, 3, 4, 5.
• These studies suggest that apixaban is effective and safe in patients with impaired renal function, including those with advanced chronic kidney disease 3, 4.

Eliquis Loading in Patients on Plavix

• There is no direct evidence to recommend Eliquis loading in patients on Plavix with acute conditions.
• However, the studies suggest that apixaban can be used in patients with atrial fibrillation and impaired renal function, and that it may be a reasonable alternative to warfarin in these patients 4.
• The decision to use apixaban in a patient on Plavix should be based on the individual patient's risk factors and medical history, and should be made in consultation with a healthcare professional.

Renal Function and Apixaban Use

• The studies suggest that apixaban is effective and safe in patients with impaired renal function, including those with advanced chronic kidney disease 3, 4.
• However, the use of apixaban in patients with severe renal impairment (eGFR < 15 mL/min/BSA) is not well studied, and should be approached with caution 5.
• The pharmacokinetics of apixaban are not significantly affected by renal impairment, and the drug can be used at the standard dose in patients with impaired renal function 3, 5.

Clinical Guidelines and Recommendations

• The use of apixaban in patients with atrial fibrillation and impaired renal function is supported by clinical guidelines and recommendations 6.
• The guidelines recommend the use of direct oral anticoagulants, including apixaban, as first-line agents for preventing stroke in patients with nonvalvular atrial fibrillation, and for treating venous thromboembolism 6.
• The guidelines also recommend the use of validated bleeding risk assessments, such as HAS-BLED, to identify patients at high risk of bleeding, and to address modifiable risk factors 6.