Can Brilinta (ticagrelor) and Eliquis (apixaban) be used together?

From the Guidelines

Brilinta (ticagrelor) and Eliquis (apixaban) can be used together, but this combination requires careful medical supervision due to increased bleeding risk, as evidenced by recent studies such as the one published in Circulation: Arrhythmia and Electrophysiology in 2022 1. This combination is sometimes prescribed for patients who have specific conditions requiring both antiplatelet therapy (Brilinta) and anticoagulation (Eliquis), such as patients with atrial fibrillation who also have recent coronary stenting. When used together, healthcare providers typically monitor patients closely and may adjust dosages to minimize bleeding complications, as suggested by guidelines and recommendations 1. Some key points to consider when using this combination include:

• The initial antiplatelet of choice in patients receiving anticoagulation during acute coronary syndrome (ACS) is clopidogrel due to the higher risk of bleeding associated with ticagrelor versus clopidogrel, however, in patients who are at exceptionally high risk for stent thrombosis, the risks of bleeding may not outweigh the benefits of ticagrelor use 1.
• The dose of aspirin should not exceed 100 mg in cases where triple therapy is used, and this combination should ideally not exceed 30 days 1.
• Apixaban was superior to warfarin in reducing bleeding events in the setting of ACS with no difference in thrombotic events, and guidelines currently recommend a DOAC over warfarin 1. Patients taking both medications should be vigilant for signs of bleeding, including unusual bruising, nosebleeds, blood in urine or stool, or prolonged bleeding from cuts. It's essential to inform all healthcare providers about this medication combination before any procedures, including dental work, and to carefully weigh the risks and benefits of this combination therapy, as supported by studies such as the 2019 AHA/ACC/HRS focused update on atrial fibrillation 1. The rationale for this combination is that Brilinta prevents platelets from sticking together (preventing arterial clots), while Eliquis inhibits specific clotting factors in the blood (preventing venous clots), addressing different aspects of clot formation when both mechanisms need to be targeted. In clinical practice, the decision to use Brilinta and Eliquis together should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history, and guided by the most recent and highest quality evidence available, such as the study published in Circulation: Arrhythmia and Electrophysiology in 2022 1.

From the Research

Combination Therapy with Brilinta and Eliquis

• The provided studies do not directly address the use of Brilinta (ticagrelor) and Eliquis (apixaban) together in patients.
• However, studies such as 2 and 3 discuss the use of dual therapy with dabigatran (a different anticoagulant) and ticagrelor or clopidogrel in patients with atrial fibrillation and acute coronary syndrome.
• These studies suggest that dual therapy with an anticoagulant and an antiplatelet agent can be effective in reducing bleeding risks and preventing thrombotic events.

Antiplatelet and Anticoagulant Therapy

• The standard of care for acute coronary syndromes typically involves dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor antagonist, such as clopidogrel or ticagrelor 4.
• Novel P2Y12 receptor antagonists like prasugrel and ticagrelor are recommended over clopidogrel in certain clinical guidelines due to their improved efficacy and faster onset of action 5, 6.
• The use of anticoagulants like dabigatran alongside antiplatelet agents is being investigated in patients with atrial fibrillation and acute coronary syndrome, with studies showing promising results in reducing bleeding risks and preventing thrombotic events 2, 3.

Ongoing Research and Future Directions

• Further studies are needed to investigate the safety and efficacy of combination therapy with Brilinta and Eliquis in patients with acute coronary syndrome and other indications.
• Ongoing research, such as the study registered under trial registration number NL75644.096.21, aims to compare the safety and efficacy of dabigatran plus ticagrelor versus dabigatran plus clopidogrel in patients with acute coronary syndrome and indication for non-vitamin K antagonist oral anticoagulant (NOAC) therapy 3.