Can Eliquis (apixaban) cause bullous pemphigoid?

Eliquis (Apixaban) and Bullous Pemphigoid

There is no established causal relationship between Eliquis (apixaban) and bullous pemphigoid based on current medical evidence and guidelines. While numerous medications have been associated with drug-induced bullous pemphigoid, Eliquis is not specifically identified as a causative agent in the current dermatological guidelines.

Understanding Bullous Pemphigoid

Bullous pemphigoid (BP) is an autoimmune subepidermal blistering disease that:

• Primarily affects elderly patients
• Presents with pruritus and localized or generalized bullous lesions
• Can present in non-bullous forms with excoriations, prurigo-like lesions, or eczematous lesions in up to 20% of cases 1
• Is significantly associated with neurological disorders 1, 2

Drug-Induced Bullous Pemphigoid

Drug-induced bullous pemphigoid is a recognized variant of BP:

• More than 50 different drugs have been associated with bullous pemphigoid 3
• The following medication classes have established associations with BP:
  • Dipeptidyl peptidase IV inhibitors (gliptins) 4
  • Immune checkpoint inhibitors 1, 5, 6

Evaluation of Potential Drug-Induced BP

If a patient on Eliquis develops symptoms suspicious for bullous pemphigoid:

1. Diagnostic workup should include:

   • Skin biopsy for histopathology from early bulla on erythematous skin 2
   • Direct immunofluorescence (DIF) from perilesional skin looking for linear IgG and/or C3 deposits along dermoepidermal junction 2
   • Indirect immunofluorescence (IIF) on salt-split skin 2
   • ELISA for anti-BP180 and anti-BP230 antibodies 2

2. Medication review:

   • Evaluate all medications the patient is taking
   • Consider temporal relationship between drug initiation and symptom onset
   • While there is a single case report of apixaban-associated rash 7, this was not specifically bullous pemphigoid and the patient had a pre-existing autoimmune skin condition (pemphigus vulgaris)

Management Considerations

If bullous pemphigoid is diagnosed in a patient taking Eliquis:

1. Evaluate the necessity of continuing Eliquis

   • Consider the risk-benefit ratio of continuing anticoagulation versus changing to an alternative agent
   • If anticoagulation is still required, consider switching to a different class of anticoagulant (as was done in the case report where dabigatran was substituted) 7

2. Treatment of bullous pemphigoid according to guidelines:

   • Localized disease: Superpotent topical corticosteroids 2
   • Generalized disease: Oral corticosteroids (prednisolone 0.5-0.75mg/kg/day) 2
   • Adjuvant therapies: Tetracycline + nicotinamide, azathioprine, or dapsone 2

Key Points

• The current medical literature and guidelines do not establish Eliquis as a common cause of bullous pemphigoid
• If BP develops in a patient on Eliquis, consider other more established causative medications first
• Drug-induced BP typically resolves after withdrawal of the offending medication 3
• Regular monitoring and follow-up are essential for patients with BP, with attention to both disease activity and treatment-related side effects 2

If bullous pemphigoid is suspected in a patient taking Eliquis, a dermatology consultation is warranted for proper diagnosis and management, as BP significantly impacts quality of life and carries increased mortality risk in elderly patients 1.