What needs to be considered before starting Eliquis (apixaban) in a patient?

Key Considerations Before Starting Eliquis (Apixaban)

Before starting Eliquis (apixaban), clinicians must evaluate renal function, bleeding risk, drug interactions, and appropriate dosing criteria to ensure safe and effective anticoagulation.

Renal Function Assessment

• Mandatory creatinine clearance (CrCl) measurement using the Cockcroft-Gault method 1
• Dose adjustments based on renal function:
  • Normal/mild impairment: 5 mg twice daily (CrCl >30 mL/min) 1
  • Moderate impairment: 5 mg twice daily (CrCl >30 mL/min) or consider dose reduction 1
  • Severe impairment (CrCl <30 mL/min): Use with caution; limited data available 1
  • End-stage renal disease: Not recommended by some guidelines 1

Recent evidence suggests that 5 mg dosing in severe chronic kidney disease may be associated with higher bleeding risk compared to 2.5 mg dosing, with no difference in stroke prevention 2.

Dose Reduction Criteria

Reduce dose to 2.5 mg twice daily if patient has at least two of the following 1, 3:

• Age ≥80 years
• Body weight ≤60 kg
• Serum creatinine ≥1.5 mg/dL

Bleeding Risk Assessment

• Evaluate for active or recent bleeding 3
• Assess for lesions or pathology in GI or genitourinary tract that may increase bleeding risk 1
• Consider bleeding risk factors:
  • History of prior bleeding
  • Concurrent use of antiplatelet drugs or NSAIDs
  • Advanced age
  • Frailty or fall risk
  • Thrombocytopenia or coagulation disorders

Drug Interactions

• Screen for medications that affect CYP3A4 and P-glycoprotein (P-gp) 1, 3:
  • Strong dual inhibitors of CYP3A4 and P-gp (e.g., ketoconazole): Reduce apixaban dose by 50% 4
  • P-gp inhibitors: Consider dose reduction by 25% 4
  • Strong inducers of CYP3A4 and P-gp: May reduce apixaban effectiveness

Hepatic Function

• Assess liver function before initiating therapy 1
• Contraindicated in:
  • Active/clinically significant liver disease
  • Child-Pugh Class B or C
  • ALT/AST >3x upper limit of normal (ULN)
  • Total bilirubin >2x ULN 1

Additional Considerations

• Pregnancy status: Contraindicated in pregnancy or breastfeeding 1
• Surgical planning: Discontinue 48 hours before procedures with moderate/high bleeding risk; 24 hours before low bleeding risk procedures 3
• Neuraxial anesthesia risk: Increased risk of epidural/spinal hematoma with neuraxial anesthesia or spinal puncture 3
• Patient education: Discuss importance of adherence, bleeding signs/symptoms, and not doubling doses if missed 3
• Monitoring plan: Regular assessment of renal function (at least annually) 1

Common Pitfalls to Avoid

1. Inappropriate dose reduction: Many patients receive reduced doses without meeting criteria, which may compromise efficacy 1, 5
2. Failure to adjust for drug interactions: Overlooking medications that affect CYP3A4 and P-gp 1
3. Inadequate renal function monitoring: Renal function should be evaluated before initiation and at least annually 1
4. Overlooking bleeding risk factors: Especially in elderly patients or those with multiple comorbidities 1
5. Improper perioperative management: Not discontinuing apixaban appropriately before procedures 3

By systematically evaluating these factors before initiating apixaban, clinicians can optimize therapy to maximize stroke prevention while minimizing bleeding risk.