Should this patient receive Eliquis (apixaban)?

Apixaban (Eliquis) Recommendation for Patients with Atrial Fibrillation

For patients with non-valvular atrial fibrillation who are eligible for oral anticoagulation, apixaban (Eliquis) is strongly recommended over vitamin K antagonists due to its superior safety profile and similar efficacy in preventing stroke and systemic embolism. 1

Indications for Apixaban

Apixaban is indicated for:

• Reduction of stroke and systemic embolism risk in non-valvular atrial fibrillation 2
• Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) 2
• Prophylaxis of DVT following hip or knee replacement surgery 2
• Reduction in the risk of recurrent DVT and PE 2

Dosing Algorithm

For Non-valvular Atrial Fibrillation:

• Standard dose: 5 mg twice daily 2
• Reduced dose (2.5 mg twice daily) if patient has at least two of:
  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL 2

Important Considerations:

1. Renal function:

   • Apixaban can be used in patients with mild to moderate renal impairment
   • Not recommended in severe renal impairment (CrCl <15 mL/min) 1, 2

2. Drug interactions:

   • Avoid concomitant use with strong dual inhibitors of CYP3A4 and P-gp
   • Dose adjustments may be needed with certain medications 3

3. Contraindications:

   • Active pathological bleeding
   • Severe hypersensitivity to apixaban
   • Mechanical heart valves (use warfarin instead) 1
   • Pregnancy or lactation 1

Benefits of Apixaban vs. Warfarin

• Lower risk of major bleeding 1
• Significantly reduced risk of intracranial hemorrhage 1, 4
• No need for routine INR monitoring 1
• Fixed dosing with fewer drug-food interactions 5
• Superior net clinical benefit (balancing stroke prevention and bleeding risk) 1

Special Situations

Perioperative Management:

• For low bleeding risk procedures: discontinue apixaban 24 hours before
• For high bleeding risk procedures: discontinue 48 hours before
• Resume 24-72 hours after procedure based on bleeding risk 3
• No bridging anticoagulation needed due to rapid onset/offset 3

Acute Coronary Syndrome/PCI:

• Appropriately reduced dose apixaban shows lower bleeding risk compared to vitamin K antagonists in patients with AF and recent ACS or PCI 6

Switching Between Anticoagulants:

• From warfarin to apixaban: Start apixaban when INR <2.0
• From apixaban to warfarin: Consider overlap with parenteral anticoagulant 2

Monitoring Recommendations

• Regular assessment of renal function (at least annually) 1
• Routine re-evaluation 3-6 months after initiation 1
• Regular assessment of bleeding risk, drug tolerance, and adherence 1
• No routine coagulation monitoring required 5

Common Pitfalls to Avoid

1. Inappropriate dose reduction: Many patients receive reduced-dose apixaban without meeting criteria, which may compromise stroke prevention 6, 7

2. Failure to adjust dose when patient meets criteria for dose reduction, increasing bleeding risk 7

3. Combining with antiplatelet therapy without clear indication, which significantly increases bleeding risk 1

4. Discontinuing without transition to another anticoagulant, which increases thrombotic risk 2

5. Overlooking drug interactions that may affect apixaban levels 3

Apixaban represents a significant advancement in anticoagulation therapy for patients with non-valvular atrial fibrillation, offering an improved safety profile while maintaining efficacy in stroke prevention compared to traditional vitamin K antagonists.