Is Eliquis (apixaban) a suitable anticoagulant option?

Eliquis (Apixaban) as an Anticoagulant Option

Eliquis (apixaban) is a highly effective and recommended anticoagulant with a favorable safety profile compared to warfarin and other direct oral anticoagulants (DOACs) for most patients requiring anticoagulation. 1, 2

Indications and Effectiveness

Apixaban is FDA-approved for:

• Reducing stroke and systemic embolism risk in nonvalvular atrial fibrillation
• Prophylaxis of deep vein thrombosis (DVT) after hip or knee replacement
• Treatment of DVT and pulmonary embolism (PE)
• Reducing risk of recurrent DVT and PE following initial therapy 2

In atrial fibrillation patients:

• Apixaban demonstrated superiority to warfarin in reducing stroke and systemic embolism (1.27% vs 1.60% per year) 2
• Particularly effective at reducing hemorrhagic stroke compared to warfarin (0.24% vs 0.47% per year) 2
• Significantly more effective than aspirin in patients unsuitable for vitamin K antagonist therapy 2, 3

Safety Profile

Apixaban offers significant safety advantages:

• Lower risk of major bleeding compared to warfarin (2.13% vs 3.09% per year) 2
• Significantly reduced risk of intracranial hemorrhage compared to warfarin 2, 4
• Better safety profile compared to other DOACs (dabigatran and rivaroxaban) with:
  • 35% relative risk reduction in major bleeding vs dabigatran
  • 46% relative risk reduction in major bleeding vs rivaroxaban
  • Lower risk of gastrointestinal bleeding compared to all other oral anticoagulants 4

Dosing Considerations

Standard dosing for nonvalvular atrial fibrillation:

• 5 mg twice daily for most patients
• Reduced dose of 2.5 mg twice daily if patient has at least 2 of the following:
  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL 2

For patients with severe renal impairment:

• The 2.5 mg twice daily dose is recommended for patients with severe chronic kidney disease (CKD stage 4/5)
• Higher doses (5 mg twice daily) in severe CKD are associated with increased bleeding risk without improved effectiveness 5

Contraindications and Cautions

Apixaban should not be used in:

• Patients with mechanical heart valves
• Patients with moderate to severe mitral stenosis 1
• Patients with severe hepatic impairment 1

Exercise caution in:

• Patients with antiphospholipid syndrome (vitamin K antagonists preferred) 1
• Patients with active cancer with luminal GI malignancies (may consider LMWH instead) 1

Advantages Over Other Anticoagulants

Compared to warfarin:

• No routine coagulation monitoring required
• Fewer drug-drug interactions
• Fixed dosing
• Lower risk of intracranial hemorrhage
• No dietary restrictions 1

Compared to other DOACs:

• Better safety profile with lower bleeding risks 4
• Can be used in patients with moderate renal impairment with appropriate dose adjustment 5

Practical Considerations

• For procedures with low bleeding risk: stop apixaban 24 hours before
• For procedures with high bleeding risk: stop apixaban 48 hours before
• No bridging anticoagulation typically needed
• If switching from warfarin to apixaban, discontinue warfarin and start apixaban when INR <2.0

Common Pitfalls to Avoid

• Failing to adjust dose in elderly patients, those with low body weight, or renal impairment
• Inappropriate co-administration with other anticoagulants or antiplatelet agents (increases bleeding risk)
• Not considering drug interactions that may affect apixaban levels
• Abrupt discontinuation without appropriate bridging or transition to another anticoagulant

In conclusion, Eliquis (apixaban) is a highly effective anticoagulant with an excellent safety profile that makes it a preferred option for most patients requiring anticoagulation, particularly those with nonvalvular atrial fibrillation or venous thromboembolism.