Is Eliquis (apixaban) safe to use during pregnancy?

Apixaban (Eliquis) Use During Pregnancy

Apixaban is not recommended for use during pregnancy due to unknown risks to the fetus and lack of adequate human safety data. 1, 2

Evidence on Apixaban in Pregnancy

Safety Concerns

The International Society on Thrombosis and Haemostasis (ISTH) and American College of Chest Physicians (ACCP) guidelines explicitly recommend against using direct oral anticoagulants (DOACs), including apixaban, during pregnancy:

• There are no adequate human data on apixaban use in pregnant women 1
• The ACCP guidelines specifically recommend "avoiding the use of oral direct thrombin and anti-Xa inhibitors (including apixaban)" during pregnancy (Grade 1C recommendation) 1
• The FDA label for apixaban states that available data on use in pregnant women are insufficient to inform drug-associated risks 2

Potential Risks

While animal studies with apixaban did not show reproductive toxicity (unlike some other DOACs), this does not guarantee human safety:

• A systematic review identified 236 cases of DOAC use during pregnancy, with concerning findings including a 31% miscarriage rate and 4% rate of fetal anomalies with rivaroxaban (another factor Xa inhibitor similar to apixaban) 3
• The FDA label notes that anticoagulant treatment may increase bleeding risk during pregnancy and delivery 2
• DOACs have unknown potential for reproductive toxicity in humans 1

Alternative Anticoagulation During Pregnancy

For pregnant women requiring anticoagulation, the evidence strongly supports using:

1. Low Molecular Weight Heparin (LMWH) - First-line therapy for pregnant women

   • Does not cross the placenta 4
   • Extensive safety data during pregnancy 1
   • Recommended for treatment of VTE in pregnancy 1

2. Unfractionated Heparin (UFH) - Alternative option

   • Does not cross the placenta 4
   • Long history of safe use in pregnancy 5
   • May be preferred in situations requiring rapid reversal 6

Management Algorithm for Women on Apixaban Who Become Pregnant

1. Immediately discontinue apixaban upon confirmation of pregnancy
2. Consult with hematology and high-risk obstetrics for management
3. Switch to LMWH at appropriate therapeutic or prophylactic dosing based on indication
4. Monitor closely throughout pregnancy for both thrombotic and bleeding complications
5. Plan for delivery with appropriate anticoagulant management

Special Considerations

• Breastfeeding: Apixaban and/or its metabolites may accumulate in breast milk (based on animal data). Breastfeeding is not recommended during apixaban treatment 2
• Conception planning: For women requiring long-term anticoagulation who are planning pregnancy, frequent pregnancy testing and switching to LMWH upon confirmation of pregnancy is recommended rather than preemptive switching 1
• Postpartum period: After delivery, women may be transitioned to warfarin (which is safe during breastfeeding) or potentially back to apixaban if not breastfeeding 1

Key Pitfalls to Avoid

1. Continuing apixaban after pregnancy is confirmed - Switch to LMWH immediately
2. Assuming similar safety profiles across all anticoagulants - DOACs have specific concerns in pregnancy not shared by heparins
3. Inadequate monitoring during transition between anticoagulants - Ensure therapeutic coverage during switches
4. Failing to plan for delivery - Coordinate with obstetrics and anesthesiology for appropriate peripartum anticoagulation management

The evidence clearly indicates that apixaban should be avoided during pregnancy, with LMWH being the anticoagulant of choice for pregnant women requiring anticoagulation.