Should a patient who has had recent hip surgery continue taking Eliquis (apixaban) and aspirin together?

Management of Apixaban and Aspirin After Recent Hip Surgery

Patients who have had recent hip surgery should discontinue the combination of Eliquis (apixaban) and aspirin together, as this dual therapy significantly increases bleeding risk without providing additional thromboprophylactic benefit.

Rationale for Recommendation

Apixaban alone is highly effective for VTE prophylaxis after hip surgery, making the addition of aspirin unnecessary and potentially harmful:

• Apixaban has been proven superior to enoxaparin for VTE prevention after hip arthroplasty in the ADVANCE-3 trial (1.4% vs 3.9% VTE incidence) 1
• The FDA-approved indication for apixaban includes VTE prophylaxis after hip replacement surgery 2
• Combining apixaban with aspirin significantly increases bleeding risk without providing additional protection against thromboembolism 2

Standard Thromboprophylaxis Protocol After Hip Surgery

Apixaban Monotherapy

• Dosage: 2.5 mg twice daily 1, 3
• Duration: 35 days after hip surgery 1, 3
• Timing: Starting 12-24 hours after surgery (once hemostasis is achieved) 3

Monitoring and Precautions

• Ensure adequate renal function (dose adjustment may be needed if CrCl is 30-50 mL/min) 1, 3
• Check for drug interactions, particularly P-glycoprotein inhibitors and CYP3A4 inhibitors 1, 2
• Monitor for signs of bleeding:
  • Unexpected bleeding or bruising
  • Red/pink/brown urine
  • Red or black stools
  • Coughing up blood
  • Vomiting blood 2

Bleeding Risk Considerations

The FDA label for apixaban specifically warns about increased bleeding risk when combined with other medications that increase bleeding risk, including:

• Aspirin or aspirin-containing products
• NSAIDs
• Other anticoagulants 2

Evidence Supporting Apixaban Monotherapy

Apixaban has demonstrated excellent efficacy and safety profile for VTE prophylaxis after hip surgery:

• In the ADVANCE-3 trial, apixaban showed superior efficacy compared to enoxaparin with a relative risk reduction of 64% (RR 0.36; 95% CI 0.22-0.54) 1
• Rates of major or clinically relevant non-major bleeding were numerically lower with apixaban than with enoxaparin 1
• Recent studies confirm apixaban's safety and efficacy in preventing VTE after hip arthroplasty 4, 5

Special Considerations

• For patients at very high thrombotic risk, consult with a hematologist for personalized recommendations
• If the patient was on apixaban for atrial fibrillation prior to surgery, they should return to their regular dosing schedule (typically 5 mg twice daily) after the thromboprophylaxis period ends 3, 2
• If aspirin was prescribed for another indication (e.g., coronary artery disease), consider temporarily discontinuing it during the apixaban treatment period and resuming it after completing the thromboprophylaxis course

Common Pitfalls to Avoid

• Premature initiation of apixaban before adequate hemostasis is achieved
• Inappropriate dosing (using atrial fibrillation dosing instead of VTE prophylaxis dosing)
• Inadequate duration of prophylaxis (should be 35 days for hip surgery)
• Failure to adjust for renal function
• Not accounting for drug interactions that affect apixaban metabolism 3

By following these guidelines, patients can receive optimal thromboprophylaxis after hip surgery while minimizing bleeding risk.