From the Guidelines
Apixaban is contraindicated in patients with pregnancy or breastfeeding, stage IV/V chronic kidney disease (CrCl <30 mL/min), active/clinically significant liver disease, and those taking strong dual inhibitors/inducers of CYP3A4 and P-gp. The use of apixaban in patients with severe renal impairment, especially those on hemodialysis, is not recommended due to insufficient data on safe dosing 1. Additionally, apixaban should be used with caution in patients with compromised renal or liver function, as well as those with genitourinary or GI tract lesions, pathology, or instrumentation, due to an increased risk of bleeding 1.
When considering the use of apixaban, it is essential to weigh the benefits against the potential risks, particularly in patients with certain comorbidities or those taking concomitant medications that may interact with apixaban 1. The medication's mechanism of action, inhibiting Factor Xa in the coagulation cascade, explains the primary concern of bleeding with its use.
Key points to consider when prescribing apixaban include:
- Contraindications: pregnancy or breastfeeding, stage IV/V chronic kidney disease, active/clinically significant liver disease, and strong dual inhibitors/inducers of CYP3A4 and P-gp
- Caution in patients with severe renal impairment, compromised renal or liver function, and genitourinary or GI tract lesions, pathology, or instrumentation
- Monitoring for bleeding and adjusting dosage as necessary in patients with renal impairment or those taking concomitant medications that may interact with apixaban 1.
From the FDA Drug Label
Apixaban tablets are contraindicated in patients with the following conditions: • Active pathological bleeding [see Warnings and Precautions (5.2) and Adverse Reactions(6.1)] • Severe hypersensitivity reaction to apixaban (e.g., anaphylactic reactions) [see Adverse Reactions (6.1)]
The contraindications for Apixaban are:
- Active pathological bleeding
- Severe hypersensitivity to apixaban (e.g., anaphylactic reactions) 2
From the Research
Contraindications for Apixaban
The following are contraindications for apixaban:
- Active bleeding or a high risk of bleeding 3
- Severe hepatic impairment 3
- Hepatic disease associated with coagulopathy and clinically relevant bleeding risk 3
- Concomitant use of other anticoagulants or antiplatelet agents that may increase the risk of bleeding 4
Special Considerations
Apixaban should be used with caution in patients with:
- Mild or moderate hepatic impairment (Child-Pugh A or B) 3
- Renal impairment, particularly those with a creatinine clearance < 25 mL/min 5, 6
- Acute kidney injury, as it may increase the risk of bleeding 4
- End-stage renal disease on hemodialysis, as it may require dose adjustments and close monitoring for bleeding events 6, 7
Bleeding Risk Factors
The following factors may increase the risk of bleeding with apixaban: