What are the considerations for using aspirin and Eliquis (apixaban) together in patients with non-valvular atrial fibrillation?

From the Guidelines

Combining aspirin and Eliquis (apixaban) in patients with non-valvular atrial fibrillation is generally not recommended unless there is a specific clinical indication such as recent acute coronary syndrome or coronary stent placement. The combination significantly increases bleeding risk without providing substantial additional benefit in stroke prevention for most patients. When Eliquis is used as the primary anticoagulant at its standard dose (5 mg twice daily, or 2.5 mg twice daily for patients meeting dose-reduction criteria), adding aspirin increases the risk of major bleeding by approximately 50-100% compared to Eliquis alone 1. If dual therapy is clinically necessary, the lowest effective dose of aspirin (usually 81 mg daily) should be used, and the duration should be limited to the shortest time required (typically 1-6 months after coronary intervention, depending on stent type and bleeding risk) 1. Patients on combination therapy require closer monitoring for bleeding complications, including regular assessment for bruising, blood in stool, and unusual bleeding. The increased bleeding risk occurs because Eliquis inhibits Factor Xa in the coagulation cascade, while aspirin irreversibly inhibits platelet function through a different mechanism, creating two separate disruptions to hemostasis that compound bleeding risk. Some key considerations for the use of anticoagulants in non-valvular atrial fibrillation include:

• The patient's risk of stroke, as determined by their CHADS2 score or other risk assessment tools
• The patient's risk of bleeding, as determined by their HAS-BLED score or other bleeding risk assessment tools
• The patient's kidney function, as apixaban is contraindicated in patients with severe kidney disease
• The patient's liver function, as apixaban is metabolized by the liver and may require dose adjustment in patients with liver disease
• The potential for drug interactions, as apixaban may interact with other medications that affect coagulation or platelet function. Overall, the decision to combine aspirin and Eliquis in patients with non-valvular atrial fibrillation should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 1.

From the FDA Drug Label

• concomitant use of other drugs that affect hemostasis, such as nonsteroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors, other anticoagulants The use of aspirin and Eliquis (apixaban) together in patients with non-valvular atrial fibrillation may increase the risk of bleeding due to their combined effects on hemostasis.

• Key considerations:
  • Aspirin is a platelet inhibitor and Eliquis is an anticoagulant
  • Concomitant use may increase the risk of bleeding
  • Patients should be monitored frequently for signs and symptoms of bleeding 2

From the Research

Considerations for Using Aspirin and Eliquis Together

When considering the use of aspirin and Eliquis (apixaban) together in patients with non-valvular atrial fibrillation, several factors come into play.

• The risk of bleeding is a significant concern when combining anticoagulants and antiplatelet agents 3, 4.
• Patients with atrial fibrillation and stable coronary artery disease may not benefit from the combination of aspirin and oral anticoagulant therapy, as it may increase the risk of major bleeding with little to no benefit in preventing ischemic events 3.
• The ARISTOTLE trial found that apixaban was effective in reducing stroke or systemic embolism and death in patients with atrial fibrillation, regardless of the presence of prior coronary artery disease 5, 6.
• In patients with atrial fibrillation who undergo percutaneous coronary intervention (PCI), dropping aspirin from the triple therapy regimen to create "dual" therapy (oral anticoagulants and P2Y12 inhibitors alone) may reduce bleeding without a significant increase in ischemic events 7.

Patient Selection and Risk Stratification

Patient selection and risk stratification are crucial when deciding whether to use aspirin and Eliquis together.

• Factors such as prior coronary artery disease, myocardial infarction, and diabetes may increase the likelihood of receiving combined antiplatelet and anticoagulant therapy 3, 6.
• The risk of bleeding and ischemic events should be carefully assessed, and the decision to use aspirin and Eliquis together should be individualized based on the patient's specific risk profile 7, 4.
• Current recommendations suggest using dual therapy (oral anticoagulants and P2Y12 inhibitors alone) as the default regimen, with triple therapy reserved for selected high ischemic risk patients 7.