Can you give Eliquis (apixaban)?

Apixaban (Eliquis) Administration Guidelines

Apixaban can be given but should be avoided in patients with severe renal impairment (CrCl <15 mL/min) or significant hepatic impairment, and dose adjustments are required for specific patient populations.

Indications and Standard Dosing

• Apixaban is a direct factor Xa inhibitor approved for:

  • Prevention of stroke and systemic embolism in non-valvular atrial fibrillation
  • Treatment and prevention of venous thromboembolism (VTE)
  • Thromboprophylaxis following hip or knee replacement surgery

• Standard dosing for non-valvular atrial fibrillation: 5 mg twice daily 1

• Standard dosing for VTE treatment: 10 mg twice daily for 7 days, followed by 5 mg twice daily 2

Dose Adjustment Criteria

Reduce dose to 2.5 mg twice daily if patient has at least two of the following:

• Age ≥80 years
• Body weight ≤60 kg
• Serum creatinine ≥1.5 mg/dL 2, 1

Contraindications

• Active pathological bleeding 3
• Severe hypersensitivity reaction to apixaban 3
• Severe renal impairment (CrCl <15 mL/min) 2
• Significant hepatic impairment (transaminases >2 times upper limit of normal or total bilirubin >1.5 times upper limit of normal) 2
• Pregnancy or breastfeeding 3

Drug Interactions

• Reduce apixaban dose by 50% when co-administered with strong dual inhibitors of CYP3A4 and P-glycoprotein (e.g., ketoconazole, itraconazole, ritonavir) 3
• For patients already on 2.5 mg twice daily, avoid co-administration with combined P-gp and strong CYP3A4 inhibitors 3
• Use caution when combining with medications that increase bleeding risk:
  • Antiplatelet agents
  • Other anticoagulants
  • NSAIDs
  • SSRIs/SNRIs 1, 3

Special Populations

Renal Impairment

• Mild to moderate impairment (CrCl 30-50 mL/min): No dose adjustment required unless other dose reduction criteria are met 2
• Severe impairment (CrCl <30 mL/min): Use with caution; consider alternative anticoagulants 2
• End-stage renal disease on dialysis: Not recommended 2

Hepatic Impairment

• Avoid in patients with significant hepatic impairment 2
• Not recommended in patients with Child-Pugh Class B or C or elevated liver enzymes (ALT/AST >3x ULN) 2

Cancer Patients

• Limited data exists on apixaban use in cancer patients
• NCCN guidelines (2013) did not recommend apixaban for thromboprophylaxis or VTE treatment in cancer patients due to insufficient clinical data 2
• More recent guidelines (2024) include apixaban as an option but with caution in specific cancer populations 2

Monitoring

• No routine coagulation monitoring required 1
• Regular assessment of renal and hepatic function recommended
• Monitor for signs of bleeding:
  • Unexplained bruising
  • Blood in urine or stool
  • Prolonged bleeding from minor cuts
  • Unusual headaches or dizziness 1

Important Considerations

• Apixaban should be discontinued at least 48 hours prior to elective surgery with moderate to high bleeding risk 3
• If a dose is missed, take as soon as remembered on the same day and resume twice-daily dosing; do not double the dose 3
• Patient education about medication adherence is crucial, as missed doses increase thrombotic risk 1
• Premature discontinuation increases risk of thrombotic events 3

Common Pitfalls to Avoid

1. Off-label dose reduction without meeting criteria may compromise efficacy 4
2. Failing to recognize drug interactions, particularly with dual inhibitors of CYP3A4 and P-glycoprotein
3. Not considering alternative anticoagulants in patients with severe renal impairment
4. Abrupt discontinuation without appropriate bridging or transition to another anticoagulant

Apixaban offers advantages of fixed dosing, no routine monitoring requirements, and improved safety profile compared to warfarin, but proper patient selection and dosing are essential for optimal outcomes.