Should aspirin be continued with Eliquis (apixaban) for atrial fibrillation (AFib)?

Aspirin Should Not Be Combined with Eliquis (Apixaban) for Atrial Fibrillation

For patients with atrial fibrillation on Eliquis (apixaban), aspirin should be discontinued unless there is a specific indication such as recent acute coronary syndrome or coronary stenting within the past 1-4 weeks. 1

Rationale for Discontinuing Aspirin

The combination of oral anticoagulants with antiplatelet therapy significantly increases bleeding risk without providing additional stroke prevention benefits in most patients with atrial fibrillation:

• The American College of Cardiology/American Heart Association guidelines specifically state that the safety and efficacy of combining DOACs (including apixaban) with antiplatelet agents have not been established 1
• For patients with AF and stable coronary artery disease (no acute coronary syndrome within the previous year), guidelines suggest oral anticoagulation alone rather than the combination of anticoagulation and aspirin 1
• The AUGUSTUS trial demonstrated that aspirin doubled total bleeding risk compared to placebo without significantly changing total ischemic events in patients with AF 2

Evidence Supporting Apixaban Monotherapy

Apixaban alone is highly effective for stroke prevention in atrial fibrillation:

• In the ARISTOTLE trial, apixaban was significantly better than warfarin, with fewer overall strokes and major bleeding events 1
• The AVERROES study demonstrated that apixaban was superior to aspirin alone for preventing stroke or systemic embolism in patients deemed unsuitable for warfarin therapy 1, 3
• Adding aspirin to anticoagulation increases the risk of major bleeding with little to no benefit in preventing ischemic events in patients with stable coronary disease 4

Special Circumstances Where Combination Therapy May Be Considered

There are limited situations where temporary combination therapy might be warranted:

1. Recent Acute Coronary Syndrome or PCI:

   • Triple therapy (OAC + DAPT) for 1-3 months, followed by dual therapy with OAC plus single antiplatelet (preferably clopidogrel) up to 12 months, then OAC monotherapy 1
   • For patients at high bleeding risk, dual therapy (OAC + single antiplatelet) may be preferred from the outset 1

2. High Thrombotic Risk with Low Bleeding Risk:

   • Triple therapy for up to 4 weeks may be reasonable, but the default should be dual antithrombotic therapy (P2Y12 inhibitor plus DOAC) from the outset 1

Practical Recommendations

1. For most AF patients on apixaban: Use apixaban monotherapy without aspirin

2. For AF patients with recent coronary stenting: Follow a time-limited approach:

   • Discontinue aspirin after 1-4 weeks while maintaining P2Y12 inhibitor plus apixaban
   • Continue P2Y12 inhibitor plus apixaban for up to 12 months
   • Transition to apixaban monotherapy thereafter

3. For AF patients with stable CAD: Use apixaban monotherapy without aspirin

Common Pitfalls to Avoid

• Continuing aspirin by default: Many patients are inappropriately maintained on both aspirin and anticoagulation without clear indications 4
• Failure to reassess: Not reevaluating the need for combination therapy after the recommended duration
• Overlooking bleeding risk: Not considering the substantially increased bleeding risk with combination therapy

By following these evidence-based recommendations, clinicians can optimize stroke prevention while minimizing bleeding complications in patients with atrial fibrillation requiring anticoagulation with apixaban.