Can you start Eliquis (apixaban) and aspirin for a patient with coronary artery disease (CAD) and atrial fibrillation (Afib)?

From the Guidelines

Starting both Eliquis (apixaban) and aspirin for a patient with both coronary artery disease (CAD) and atrial fibrillation (AFib) is generally not recommended as standard practice. For most patients with this combination, Eliquis alone at the standard dose (5 mg twice daily, or 2.5 mg twice daily for patients meeting dose reduction criteria) is typically sufficient 1. Adding aspirin to Eliquis significantly increases bleeding risk without providing substantial additional benefit for most patients. However, there are specific situations where dual therapy might be considered, such as in patients who have recently undergone coronary stenting, experienced an acute coronary syndrome, or have a particularly high thrombotic risk.

In these cases, the combination would typically be time-limited (usually 1-6 months depending on clinical factors), with the lowest effective aspirin dose (usually 81 mg daily) 1. The decision to use dual therapy should involve careful assessment of both bleeding and thrombotic risks, and should be regularly reassessed. Key considerations include:

• The patient's overall risk of thrombotic events, such as stroke or myocardial infarction
• The patient's risk of bleeding, including any history of bleeding events or predisposing factors
• The specific clinical context, such as recent coronary stenting or acute coronary syndrome

The preference for anticoagulation alone in most AFib patients with stable CAD stems from clinical trials showing that anticoagulants effectively prevent both stroke and coronary events, while the added bleeding risk from aspirin often outweighs its incremental benefit 1. It's essential to weigh these factors carefully and consider the most recent guidelines and evidence when making treatment decisions for patients with CAD and AFib.

From the FDA Drug Label

Apixaban can cause bleeding which can be serious and rarely may lead to death. This is because apixaban is a blood thinner medicine that reduces blood clotting You may have a higher risk of bleeding if you take apixaban tablets and take other medicines that increase your risk of bleeding, including: aspirin or aspirin-containing products long-term (chronic) use of nonsteroidal anti-inflammatory drugs (NSAIDs) warfarin sodium (COUMADIN®, JANTOVEN®) any medicine that contains heparin selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) other medicines to help prevent or treat blood clots Coadministration of antiplatelet agents, fibrinolytics, heparin, aspirin, and chronic NSAID use increases the risk of bleeding In ARISTOTLE, concomitant use of aspirin increased the bleeding risk on apixaban from 1.8% per year to 3.4% per year

The use of Eliquis (apixaban) and aspirin for a patient with coronary artery disease (CAD) and atrial fibrillation (Afib) may increase the risk of bleeding.

• The combination of apixaban and aspirin can increase the risk of bleeding, as both medications affect blood clotting.
• The decision to start both medications should be made with caution, considering the patient's individual risk factors for bleeding and the potential benefits of the combination therapy.
• It is essential to closely monitor the patient for signs of bleeding and adjust the treatment plan as needed.
• The FDA drug label recommends that patients taking apixaban should be aware of the increased risk of bleeding and report any signs of bleeding to their doctor immediately 2.
• Clinical trials, such as ARISTOTLE, have shown that concomitant use of aspirin with apixaban increases the bleeding risk 2.

From the Research

Starting Eliquis and Aspirin for CAD and Afib

• The decision to start Eliquis (apixaban) and aspirin for a patient with coronary artery disease (CAD) and atrial fibrillation (Afib) depends on various factors, including the patient's individual risk of stroke, bleeding, and ischemic events 3, 4.
• Studies have shown that apixaban is effective in reducing the risk of stroke and systemic embolism in patients with Afib, with or without prior CAD 4.
• The combination of apixaban and aspirin may be considered for patients with CAD and Afib, but the risk of bleeding should be carefully evaluated 5, 6.
• The AUGUSTUS trial is an ongoing study that aims to evaluate the safety of apixaban vs. vitamin K antagonist and aspirin vs. placebo in patients with Afib and acute coronary syndrome and/or percutaneous coronary intervention 5.
• Another study suggests that antithrombotic options in CAD alone, in Afib alone, and in their combination, should be carefully considered to minimize the risk of bleeding and ischemic events 7.
• Expert consensus recommends triple therapy with warfarin, aspirin, and clopidogrel for patients with Afib undergoing coronary artery stenting, but acknowledges that the optimal antithrombotic treatment is currently undefined and may be associated with an increased risk of major bleeding 6.

Key Considerations

• The patient's individual risk factors, such as history of bleeding, kidney function, and concomitant medications, should be taken into account when deciding to start Eliquis and aspirin 3, 4.
• Regular monitoring of the patient's condition and adjustment of the treatment regimen as needed is crucial to minimize the risk of adverse events 5, 7.
• The potential benefits and risks of combining apixaban and aspirin should be carefully weighed, and alternative treatment options should be considered if necessary 6.

Treatment Regimens

• Apixaban has been shown to be effective in reducing the risk of stroke and systemic embolism in patients with Afib, with or without prior CAD, and may be considered as a treatment option for patients with CAD and Afib 4.
• The combination of apixaban and aspirin may be considered for patients with CAD and Afib, but the risk of bleeding should be carefully evaluated 5, 6.
• Alternative treatment regimens, such as warfarin and clopidogrel, may be considered for patients with Afib undergoing coronary artery stenting, but the optimal antithrombotic treatment is currently undefined 6.