Can patients with atrial fibrillation (AFib) be on Eliquis (apixaban) and aspirin and Clopidogrel (Plavix) at the same time?

From the Guidelines

It is generally not recommended for patients with atrial fibrillation to take Eliquis (apixaban), aspirin, and clopidogrel all at the same time due to the increased risk of bleeding without proportional benefits in most cases. The most recent and highest quality study, the 2019 AHA/ACC/HRS focused update on atrial fibrillation 1, suggests that double therapy with an anticoagulant and a single antiplatelet agent is superior to triple therapy in reducing bleeding complications without compromising efficacy.

Key Considerations

• The PIONEER AF-PCI and RE-DUAL PCI trials demonstrated that double antithrombotic therapy with a non-vitamin K antagonist oral anticoagulant (NOAC) and a P2Y12 inhibitor is associated with fewer bleeding complications compared to triple therapy with a vitamin K antagonist, aspirin, and a P2Y12 inhibitor 1.
• A meta-analysis of trials testing double versus triple therapy showed a halving of the odds of major and minor bleeding with double therapy compared to triple therapy, with no apparent increase in major adverse cardiovascular events 1.
• The decision to use any combination of these medications should be made by a cardiologist who can carefully weigh individual bleeding risk against thrombotic risk.

Monitoring and Precautions

• Blood tests to monitor kidney function and complete blood counts are important for patients on these medications.
• Any unusual bleeding, including nosebleeds, bleeding gums, or blood in urine or stool, should prompt immediate medical attention.
• In specific situations, such as when a patient has both atrial fibrillation and has recently received a coronary stent, a limited duration of triple therapy might be necessary, but this would typically be followed by dual therapy (usually an anticoagulant plus one antiplatelet) 1.

From the FDA Drug Label

You may have a higher risk of bleeding if you take apixaban tablets and take other medicines that increase your risk of bleeding, including: aspirin or aspirin-containing products long-term (chronic) use of nonsteroidal anti-inflammatory drugs (NSAIDs) warfarin sodium (COUMADIN®, JANTOVEN®) any medicine that contains heparin selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) other medicines to help prevent or treat blood clots Tell your doctor if you take any of these medicines.

Patients with atrial fibrillation (AFib) should use caution when taking Eliquis (apixaban) and aspirin and Clopidogrel (Plavix) at the same time, as this combination may increase the risk of bleeding. It is recommended to inform your doctor if you are taking any of these medications. 2

From the Research

Antithrombotic Therapy for Atrial Fibrillation and Coronary Heart Disease

• Patients with atrial fibrillation (AFib) and coronary heart disease (CHD) often require antithrombotic therapy to prevent stroke and coronary events 3, 4.
• The use of triple antithrombotic therapy, including oral anticoagulation, aspirin, and clopidogrel, is sometimes necessary, but it increases the risk of bleeding 3, 5.
• Recent clinical trials have shown that dual antithrombotic therapy with a non-vitamin K antagonist oral anticoagulant (NOAC) and a P2Y12 inhibitor may be a safer and effective alternative to triple therapy 5, 6.

Eliquis (Apixaban) and Aspirin and Clopidogrel (Plavix) Therapy

• There is evidence to suggest that apixaban, a NOAC, can be used in combination with aspirin and clopidogrel for patients with AFib and CHD, but the duration of triple therapy should be as short as possible 5, 6.
• The use of apixaban and clopidogrel, without aspirin, may be a viable option for some patients, as it has been shown to reduce the risk of bleeding while maintaining efficacy 5, 6.
• However, the decision to use triple antithrombotic therapy, including Eliquis, aspirin, and Clopidogrel, should be made on a case-by-case basis, taking into account the individual patient's risk of bleeding and thromboembolic events 7, 6.

Key Considerations

• The risk of bleeding and thromboembolic events should be assessed individually for each patient with AFib and CHD 7.
• The choice of antithrombotic therapy should be guided by current clinical guidelines and evidence-based recommendations 3, 4, 5, 7, 6.
• Patients with AFib and CHD should be closely monitored for signs of bleeding and thromboembolic events, and their antithrombotic therapy should be adjusted as needed 5, 6.