Apixaban for VTE Prevention After Knee Replacement Surgery
Yes, Eliquis (apixaban) is recommended and approved for venous thromboembolism prevention after knee replacement surgery at a dosage of 2.5 mg twice daily for 12 days. 1, 2
Efficacy and Evidence
Apixaban has been extensively studied for VTE prophylaxis following knee replacement surgery:
- In the ADVANCE-2 trial, apixaban 2.5 mg twice daily was superior to enoxaparin 40 mg once daily for prevention of VTE and all-cause mortality (1.51% vs 24.4%, RR 0.62) 3, 4
- The ADVANCE-1 trial showed similar efficacy between apixaban and enoxaparin 30 mg twice daily, though noninferiority criteria were not met 3
- Based on these results, apixaban received approval from the European Commission for VTE prevention in patients undergoing elective knee replacement surgery 3
Dosing and Administration
- Dosage: 2.5 mg taken orally twice daily 2
- Timing: Initial dose should be taken 12-24 hours after surgery, once adequate hemostasis is established 1, 2
- Duration: 12 days for knee replacement surgery 2
Advantages of Apixaban
- Oral administration provides convenience compared to injectable anticoagulants 5
- No routine monitoring required, unlike warfarin
- Lower rates of major or clinically relevant bleeding compared to some enoxaparin regimens 3, 4
- Predictable pharmacokinetic and pharmacodynamic profile 3
Important Considerations and Precautions
Renal Function
- Ensure adequate renal function before initiating therapy 1
- For patients with CrCl <50 mL/min, apixaban is preferred over dabigatran 1
- Avoid in patients with CrCl <15 mL/min 1
Drug Interactions
- Avoid concomitant use with potent inhibitors of both CYP3A4 and P-glycoprotein (e.g., ketoconazole, ritonavir) 3
- Caution with medications that increase bleeding risk 1
Perioperative Management
- Discontinue at least 24-48 hours before elective surgery depending on bleeding risk 2
- Restart only after adequate hemostasis has been established 2
Bleeding Risk
- Monitor for signs of bleeding, especially in high-risk patients 1
- No specific antidote was available at the time of these studies (note: andexanet alfa has since been developed)
Common Errors to Avoid
- Premature initiation before adequate hemostasis
- Inappropriate dosing
- Inadequate duration of prophylaxis
- Failure to adjust for renal function
- Not accounting for drug interactions 1
Alternative Options
If apixaban is contraindicated or not preferred:
- Low-molecular-weight heparin (LMWH)
- Rivaroxaban 10 mg once daily 6
- Mechanical prophylaxis (intermittent pneumatic compression) when pharmacological prophylaxis is contraindicated 1
Apixaban represents an effective, convenient option for VTE prophylaxis after knee replacement surgery with a favorable risk-benefit profile when used appropriately.