Is a rebolus of Eliquis (apixaban) necessary after a 14-day interruption?

From the Guidelines

You typically need to rebolus Eliquis (apixaban) if it has been stopped for 14 days, as the medication will have been completely cleared from your system, and you would need to restart at the initial dosing regimen as prescribed by your healthcare provider. For most patients, this means starting with the standard dose (typically 5 mg twice daily for non-valvular atrial fibrillation, or weight/indication-specific doses for other conditions) 1. Patients with certain risk factors like advanced age, low body weight, or kidney impairment might restart at a reduced dose of 2.5 mg twice daily. The reason for rebolusing is that Eliquis reaches therapeutic anticoagulation levels quickly but requires consistent dosing to maintain its blood-thinning effect. After 14 days without the medication, you would have no anticoagulant protection remaining, and restarting at the regular maintenance dose would be necessary to quickly reestablish therapeutic levels.

Some key points to consider when restarting Eliquis after a 14-day interruption include:

• The half-life of apixaban is approximately 12 hours, and it is recommended to withhold the medication for at least 2 days (approximately 4-5 half-lives) before a surgery or procedure to minimize the risk of bleeding 1.
• The American College of Chest Physicians recommends a pharmacokinetic-based approach for the perioperative management of direct oral anticoagulants (DOACs), including apixaban, which takes into account the drug's half-life and renal clearance 1.
• It is essential to consult with your healthcare provider before restarting Eliquis after stopping it, as they may want to reassess your bleeding risk or need for bridging with another anticoagulant.

In terms of the specific dosing regimen, the following guidelines can be followed:

• For patients with normal renal function, apixaban can be restarted at the standard dose of 5 mg twice daily after a 14-day interruption 1.
• For patients with impaired renal function, a reduced dose of 2.5 mg twice daily may be necessary, and the healthcare provider should assess the patient's renal function and adjust the dose accordingly 1.

From the FDA Drug Label

If a dose of apixaban tablets is not taken at the scheduled time, the dose should be taken as soon as possible on the same day and twice-daily administration should be resumed. The dose should not be doubled to make up for a missed dose. Apixaban tablets should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established.

There is no specific guidance on a rebolus of Eliquis (apixaban) after a 14-day interruption. The FDA drug label does not answer the question.

From the Research

Rebolus of Eliquis (Apixaban) After Interruption

• The necessity of a rebolus of Eliquis (apixaban) after a 14-day interruption is not directly addressed in the provided studies 2, 3, 4, 5, 6.
• However, the studies discuss the management of anticoagulant therapy, including apixaban, in patients with renal impairment and those undergoing interventional procedures.
• According to the American Society of Interventional Pain Physicians (ASIPP) guidelines, there is good evidence that discontinuation of anticoagulant therapy with apixaban prior to interventional techniques increases safety, with individual consideration of pharmacokinetics and pharmacodynamics of the drugs and individual risk factors 2.
• The studies also discuss the risk of bleeding and thromboembolic events in patients taking apixaban, particularly in those with renal impairment 3, 4, 5, 6.
• A study on the use of apixaban in patients with kidney impairment suggests that apixaban has a favorable clinical efficacy and safety profile compared with vitamin K antagonists for patients with atrial fibrillation or venous thromboembolism and comorbid kidney impairment 5.
• Another study compares bleeding rates in patients with severe or end-stage renal disease taking standard versus reduced dose apixaban for venous thromboembolism treatment, and found that a reduced dose of apixaban may be considered when treating VTE in patients with severe or end-stage renal disease 6.

Considerations for Rebolus

• The decision to administer a rebolus of apixaban after interruption should be based on individual patient factors, including renal function, risk of bleeding, and risk of thromboembolic events.
• The ASIPP guidelines recommend considering the pharmacokinetics and pharmacodynamics of the drugs and individual risk factors when discontinuing anticoagulant therapy prior to interventional techniques 2.
• The studies suggest that apixaban has a favorable safety profile in patients with renal impairment, but the risk of bleeding and thromboembolic events should still be carefully considered 3, 4, 5, 6.