Can patients undergoing chemotherapy take Eliquis (apixaban)?

Use of Eliquis (Apixaban) During Chemotherapy

Patients undergoing chemotherapy can take Eliquis (apixaban) with appropriate risk assessment, as it has been shown to significantly reduce venous thromboembolism (VTE) risk in high-risk cancer patients receiving chemotherapy. 1

Risk Assessment and Eligibility

The decision to use apixaban during chemotherapy should be based on:

1. VTE Risk Assessment: Use the Khorana score to identify high-risk patients:

   • Very high-risk cancer types (stomach, pancreas): 2 points
   • High-risk cancer types (lung, lymphoma, gynecologic, bladder, testicular, renal): 1 point
   • Prechemotherapy platelet count ≥350,000/mL: 1 point
   • Hemoglobin <10 g/dL or use of red cell growth factors: 1 point
   • Prechemotherapy leukocyte count >11,000/mL: 1 point
   • BMI ≥35 kg/m²: 1 point
   • High risk: Score ≥3 points
   • Intermediate risk: Score 1-2 points 1

2. Contraindications to consider:

   • Active bleeding or high bleeding risk
   • Severe renal impairment (CrCl <15 mL/min)
   • Significant hepatic impairment
   • Platelet count <50,000/mm³
   • Drug interactions with strong CYP3A4 and P-glycoprotein inhibitors/inducers 1, 2

Evidence Supporting Apixaban Use During Chemotherapy

The AVERT trial demonstrated that apixaban 2.5 mg twice daily significantly reduced VTE risk in cancer patients receiving chemotherapy:

• 4.2% VTE rate with apixaban vs. 10.2% with placebo (HR 0.41; 95% CI, 0.26-0.65) 1, 3
• Effective in both metastatic and non-metastatic disease 4
• Cost-effective compared to no prophylaxis 5

Dosing and Duration

• Recommended dose: Apixaban 2.5 mg twice daily 1, 2
• Duration: Up to 6 months or longer if risk factors persist 1
• Timing: Begin within 4 weeks of starting chemotherapy 6

Bleeding Risk Considerations

• Major bleeding occurred in 3.5% of apixaban patients vs. 1.8% in placebo group (HR 2.00; 95% CI, 1.01-3.95) 1
• On-treatment major bleeding rates were not significantly different (2.1% vs. 1.1%, HR 1.89; 95% CI, 0.39-9.24) 1, 3
• Higher bleeding risk with:
  • GI or mucosal tumors
  • Concurrent antiplatelet therapy
  • History of bleeding
  • Renal or hepatic impairment 1

Monitoring Recommendations

1. Before initiating:

   • Assess renal function
   • Evaluate hepatic function
   • Check complete blood count, especially platelet count
   • Review concomitant medications for potential interactions

2. During treatment:

   • Regular assessment of renal function, particularly in elderly patients
   • Monitor for signs of bleeding
   • Assess for drug-drug interactions with chemotherapy agents 2

Important Considerations

• Apixaban does not require routine coagulation monitoring 2
• Avoid abrupt discontinuation as it increases thrombotic risk 2
• Consider alternative anticoagulation if apixaban must be temporarily interrupted 2
• Andexanet alfa is available for reversal of life-threatening bleeding 2

Drug Interactions

Particular caution is needed regarding drug interactions between apixaban and anticancer treatments:

• Potent inhibitors or inducers of P-glycoprotein can interact with apixaban
• Potent inhibitors or inducers of cytochrome P450 3A4 can interact with apixaban 1

Apixaban has emerged as an effective option for VTE prophylaxis in cancer patients receiving chemotherapy, with the convenience of oral administration and no need for routine coagulation monitoring, though careful patient selection remains essential to balance thrombosis prevention with bleeding risk.