What are the guidelines for using Eliquis (apixaban) after a stroke?

From the Guidelines

Eliquis (apixaban) is recommended for patients with nonvalvular atrial fibrillation and stroke or transient ischemic attack to reduce the risk of recurrent stroke, typically at a dose of 5 mg twice daily, with a reduced dose of 2.5 mg twice daily for patients who meet certain criteria, such as age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL, as supported by the 2021 guideline from the American Heart Association/American Stroke Association 1. The guidelines suggest that oral anticoagulation, including apixaban, is recommended to reduce the risk of recurrent stroke in patients with nonvalvular atrial fibrillation and stroke or transient ischemic attack, with a preference for apixaban, dabigatran, edoxaban, or rivaroxaban over warfarin in patients without moderate to severe mitral stenosis or a mechanical heart valve 1. Some key points to consider when prescribing Eliquis include:

• The dose of Eliquis should be adjusted based on renal function, with a reduced dose recommended for patients with severe renal impairment 1.
• Patients should be educated on the importance of daily medication adherence and the dangers of missed doses or prolonged interruptions of therapy 1.
• Concomitant antiplatelet therapy with oral anticoagulant therapy is not routinely recommended in patients with atrial fibrillation due to increased bleeding risk, unless there is a specific additional medical indication 1.
• Creatinine clearance should be routinely monitored at least once annually, and when there is a change in health status, to ensure safe use of Eliquis 1. Overall, the use of Eliquis in patients with nonvalvular atrial fibrillation and stroke or transient ischemic attack is supported by strong evidence, and its benefits in reducing the risk of recurrent stroke outweigh the potential risks, as long as patients are carefully selected and monitored, as recommended by the guidelines 1.

From the FDA Drug Label

1.1 Reduction of Risk of Stroke and Systemic Embolism in Nonvalvular Atrial Fibrillation Apixaban tablets are indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation.

The guidelines for using Eliquis (apixaban) after a stroke are to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. The recommended dose is 5 mg taken orally twice daily for most patients, but may be reduced to 2.5 mg twice daily in patients with certain characteristics, such as age greater than or equal to 80 years, body weight less than or equal to 60 kg, or serum creatinine greater than or equal to 1.5 mg/dL 2.

From the Research

Guidelines for Using Eliquis (Apixaban) After a Stroke

The use of Eliquis (apixaban) after a stroke is guided by several factors, including the patient's risk of stroke and bleeding, as well as their renal function and other individual characteristics.

• The dosage of apixaban is typically 5 mg orally twice daily, but may be reduced to 2.5 mg twice daily based on individual factors such as age, renal function, and body weight, as well as the concomitant use of potent dual inhibitors of cytochrome P450 3A4 and P-glycoprotein 3.
• Apixaban has been shown to be effective in preventing stroke and systemic embolism in patients with nonvalvular atrial fibrillation, with a lower risk of major bleeding compared to warfarin 3, 4.
• The timing of anticoagulation after a stroke is also an important consideration, with some studies suggesting that early initiation of anticoagulation with apixaban may be safe and effective in preventing recurrent strokes and hemorrhagic transformation 5.

Patient-Specific Considerations

When choosing an anticoagulant agent, including apixaban, patient-specific considerations such as age, renal function, and associated diseases must be taken into account 6.

• Tools such as the CHA2DS2-VASc and HAS-BLED scores can be used to assess stroke and bleeding risk, respectively, and guide the selection of anticoagulant therapy 6.
• The use of emerging therapies, such as factor XI inhibitors and combinations of dual antiplatelet therapy with anticoagulants, may also be considered in certain patients 6.

Safety and Efficacy

The safety and efficacy of apixaban in preventing stroke and systemic embolism have been established in several studies, including the AREST trial, which compared early anticoagulation with apixaban to warfarin in patients with atrial fibrillation and stroke or transient ischemic attack 5.

• The results of this trial suggested that early initiation of anticoagulation with apixaban may be safe and effective in preventing recurrent strokes and hemorrhagic transformation, although larger pivotal trials are needed to confirm these findings 5.