What are the side effects of Eliquis (apixaban)?

Side Effects of Eliquis (Apixaban)

Bleeding is the most significant side effect of Eliquis (apixaban), with increased risk in elderly patients (≥80 years), those with low body weight (≤60 kg), renal impairment, history of bleeding, and those taking medications that interact with apixaban. 1, 2

Common Side Effects

• Bleeding-related complications:

  • Bruising
  • Prolonged bleeding after minor cuts
  • Blood in urine or stool
  • Unusual headaches or dizziness 1
  • Intracranial hemorrhage (though at lower rates compared to warfarin) 3

• Allergic reactions:

  • Skin rash
  • Severe allergic reactions including:
    • Chest pain or tightness
    • Swelling of face or tongue
    • Trouble breathing or wheezing
    • Feeling dizzy or faint 2

Risk Factors for Bleeding

Bleeding risk is significantly increased in patients with:

1. Patient characteristics:

   • Advanced age (≥80 years)
   • Low body weight (≤60 kg)
   • Renal impairment
   • History of bleeding
   • Fall risk 1

2. Medication interactions:

   • Strong CYP3A4 inhibitors (e.g., ketoconazole, ritonavir)
   • P-glycoprotein (P-gp) inhibitors
   • SSRIs (e.g., sertraline)
   • Concurrent antiplatelet medications 1

3. Organ dysfunction:

   • Severe renal impairment (CrCl <15 mL/min)
   • Significant hepatic impairment (transaminases >2x upper limit of normal or total bilirubin >1.5x upper limit of normal) 1

Dosing Considerations to Minimize Side Effects

• Dose reduction to 2.5 mg twice daily is recommended when at least two of the following criteria are met:

  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL 1

• Patients with moderate renal impairment (CrCl ≈ 34 mL/min) should receive a reduced dose when other criteria for dose reduction are met 1

• A recent study (2023) found that in patients with severe chronic kidney disease, the 5 mg dose was associated with a higher risk of bleeding compared to the 2.5 mg dose, with no difference in stroke prevention or mortality 4

Monitoring Recommendations

• Regular monitoring for signs of bleeding
• Regular assessment of renal function, especially in patients with severe renal impairment
• Evaluate for drug interactions before prescribing new medications 1
• Patients should be informed about potential bleeding signs and when to seek medical attention 1

Special Considerations

• Pregnancy and breastfeeding: It is unknown if apixaban will harm an unborn baby or if it passes into breast milk. Patients should not take apixaban while breastfeeding 2

• Surgery or procedures: All doctors and dentists should be informed about apixaban use before any surgery, medical, or dental procedure 2

• Falls or injuries: Patients should contact their healthcare provider immediately after falls or injuries, especially head injuries 2

• Medication adherence: Patients should not stop taking apixaban without consulting their doctor, as this may increase stroke risk in atrial fibrillation patients 2

Practical Management Tips

• Take apixaban exactly as prescribed, twice daily with or without food
• Do not miss doses; if a dose is missed, take it as soon as remembered but do not take more than one dose at a time
• Ensure adequate supply of medication to avoid missing doses
• Store at room temperature (68°F to 77°F/20°C to 25°C) 2

Unlike warfarin, apixaban has predictable pharmacokinetics and does not require routine anticoagulation monitoring, which is a significant advantage 5, 6. However, the risk of bleeding remains the most important consideration when prescribing this medication.