Indications for Apixaban in Patients with Multiple Myeloma
Apixaban is indicated for thromboprophylaxis in multiple myeloma patients receiving immunomodulatory drugs (IMiDs) such as thalidomide or lenalidomide, particularly when combined with other systemic anticancer therapies or when patients have additional risk factors for venous thromboembolism (VTE). 1
Risk Assessment for VTE in Multiple Myeloma
Multiple myeloma patients have an increased risk of VTE, especially when receiving immunomodulatory drugs. The decision to use apixaban should be based on:
Treatment regimen factors:
- IMiD therapy (thalidomide, lenalidomide, pomalidomide)
- Combination with high-dose dexamethasone (≥480 mg/month)
- Combination with doxorubicin or multi-agent chemotherapy
Patient-specific risk factors:
- History of previous thromboembolism
- Immobilization
- Advanced age (≥65 years)
- Obesity (BMI ≥30)
- Central venous catheter
- Comorbidities (diabetes, infections, cardiac disease)
Dosing Recommendations
- For primary VTE prophylaxis: Apixaban 2.5 mg twice daily 2
- Duration: Throughout IMiD-based therapy, typically up to 6 months or longer if risk factors persist 2
Evidence Supporting Apixaban Use in Multiple Myeloma
The 2022 International Clinical Practice Guidelines for the Treatment and Prophylaxis of VTE in patients with cancer state that "in patients with myeloma treated with immunomodulatory drugs combined with steroids or other systemic anticancer therapies, VTE primary pharmacological prophylaxis is recommended (grade 1A)" 1.
Recent clinical evidence supports apixaban's safety and efficacy:
- A phase IV pilot study of 50 multiple myeloma patients on IMiDs receiving apixaban 2.5 mg twice daily showed no major hemorrhage or VTE events over 6 months 3
- The Myelaxat phase 2 pilot study demonstrated low rates of VTE with apixaban 2.5 mg twice daily in myeloma patients receiving immunomodulatory compounds 4
Alternative Thromboprophylaxis Options
For multiple myeloma patients receiving IMiDs, the following options have shown similar efficacy:
- Low molecular weight heparin (LMWH) at prophylactic doses
- Low-dose aspirin (100 mg daily)
- Apixaban at prophylactic doses (2.5 mg twice daily)
LMWH should be preferred for patients with additional risk factors such as prior history of thromboembolism 1.
Monitoring Recommendations
- Regular assessment of renal function, particularly in elderly patients
- Monitor for signs of bleeding (unexpected bruising, red/pink/brown urine, red/black stools, hemoptysis)
- No routine coagulation monitoring is required 2
Precautions and Contraindications
- Renal function: Avoid apixaban in patients with severe renal impairment (CrCl <15 mL/min)
- Hepatic impairment: Avoid in patients with significant hepatic disease (transaminases >2x ULN or total bilirubin >1.5x ULN) 1
- Bleeding risk: Consider alternative thromboprophylaxis in patients with active bleeding, high bleeding risk, or platelet count <50,000/μL 1
- Drug interactions: Use caution with strong CYP3A4 and P-glycoprotein inhibitors/inducers that may interact with apixaban 2
Key Practice Points
- Apixaban offers an oral alternative to LMWH for thromboprophylaxis in multiple myeloma patients
- The decision between apixaban, LMWH, and aspirin should be based on individual risk factors, with LMWH preferred for higher-risk patients
- Avoid abrupt discontinuation of apixaban as this increases thrombotic risk
- Consider alternative anticoagulation if apixaban must be temporarily interrupted
Apixaban represents an effective oral option for thromboprophylaxis in multiple myeloma patients receiving immunomodulatory therapy, with clinical evidence supporting its safety and efficacy in this population.