Can aspirin (acetylsalicylic acid) be continued in patients starting Eliquis (apixaban)?

Management of Aspirin When Starting Eliquis (Apixaban)

Aspirin should generally be discontinued when starting Eliquis (apixaban) unless there is a specific indication for dual therapy such as recent coronary stenting or acute coronary syndrome.

Decision Algorithm for Aspirin Management with Eliquis

Step 1: Determine the Indication for Anticoagulation

• Atrial fibrillation: Discontinue aspirin when starting Eliquis
• Venous thromboembolism: Discontinue aspirin when starting Eliquis
• Recent acute coronary syndrome (ACS) or stent placement: Continue aspirin temporarily (see below)

Step 2: Assess Timing Since Coronary Intervention (if applicable)

• Within 1 month of drug-eluting stent placement: Continue aspirin with Eliquis (triple therapy with P2Y12 inhibitor should be limited to 1-4 weeks maximum) 1
• 1-6 months after stent placement: Consider discontinuing aspirin and continuing P2Y12 inhibitor with Eliquis 2
• >6-12 months after stent placement: Discontinue aspirin, continue Eliquis alone 2

Step 3: Assess Bleeding Risk

• High bleeding risk factors:
  • Previous intracranial hemorrhage
  • Recent major bleeding
  • Severe renal impairment
  • Low body weight (<60 kg)
  • Age >75 years
  • Concomitant use of NSAIDs or other medications increasing bleeding risk

Evidence-Based Recommendations

For Patients with Atrial Fibrillation

In patients with atrial fibrillation who require anticoagulation, the European Society of Cardiology guidelines recommend that when oral anticoagulation is initiated, aspirin should be discontinued to reduce bleeding risk 2. The evidence clearly shows that combining aspirin with Eliquis significantly increases bleeding risk without providing additional protection against thrombotic events 3, 4.

For Patients with Recent ACS or PCI

For patients with a recent acute coronary syndrome or percutaneous coronary intervention who require anticoagulation:

• Triple therapy (aspirin + P2Y12 inhibitor + anticoagulant) should be limited to 1-4 weeks maximum 1
• After this brief period, discontinue aspirin and continue with P2Y12 inhibitor (preferably clopidogrel) plus Eliquis 2
• The AUGUSTUS trial demonstrated that apixaban plus a P2Y12 inhibitor without aspirin provided the best balance of efficacy and safety regardless of prior stroke history or multimorbidity 5, 4

For Patients with Stable Coronary Artery Disease

In patients with stable coronary artery disease (>12 months from acute event or intervention), Eliquis alone is sufficient for anticoagulation, and aspirin should be discontinued 2.

Important Considerations

Bleeding Risk

Combining aspirin with Eliquis substantially increases bleeding risk. The AUGUSTUS trial showed that patients on aspirin plus apixaban had significantly higher rates of major or clinically relevant non-major bleeding compared to those on apixaban alone 5, 6. This increased bleeding risk was consistent across all kidney function categories 6.

Special Populations

• Renal impairment: The absolute risk reduction with apixaban (compared to vitamin K antagonists) was most pronounced in those with an eGFR of 30-50 mL/min/1.73m² for bleeding events 6
• Multimorbidity: The safety advantage of apixaban over vitamin K antagonists was consistent regardless of the number of comorbidities 4

Common Pitfalls to Avoid

1. Continuing triple therapy too long: Extended triple therapy significantly increases bleeding risk without providing additional protection against thrombotic events 1
2. Abrupt discontinuation without consultation: Always consult with a cardiologist before discontinuing antiplatelet therapy in patients with recent ACS or stent placement 1
3. Failing to reassess therapy: Antithrombotic regimens should be reassessed regularly as indications change over time

Practical Approach

1. For most patients starting Eliquis, discontinue aspirin
2. If recent coronary stenting (within 1 month), continue aspirin briefly (1-4 weeks)
3. Use a proton pump inhibitor to reduce gastrointestinal bleeding risk when dual therapy is necessary 2
4. Monitor for bleeding complications and reassess the need for combination therapy at each follow-up visit