What are the risks of using Eliquis (apixaban) after a stroke?

Risks of Using Eliquis (Apixaban) After Stroke

For patients with stroke and atrial fibrillation, Eliquis (apixaban) is recommended over warfarin due to its superior safety profile with lower bleeding risks while maintaining effective stroke prevention. 1

Bleeding Risks

Eliquis increases the risk of bleeding, which is its primary safety concern. Specific bleeding risks include:

• Major bleeding: Apixaban has a 31% lower risk of major bleeding compared to warfarin (2.13% vs 3.09% per year) 2
• Hemorrhagic stroke: 49% reduced risk compared to warfarin 2
• Gastrointestinal bleeding: Lower risk compared to warfarin, dabigatran, and rivaroxaban 3
• Intracranial hemorrhage: 46% lower risk compared to warfarin 3

Risk Factors for Increased Bleeding

• Concomitant use of medications affecting hemostasis:
  • Aspirin or other antiplatelet agents
  • NSAIDs
  • SSRIs/SNRIs
  • Other anticoagulants 4
• Advanced age (≥80 years)
• Low body weight (≤60 kg)
• Impaired renal function (serum creatinine ≥1.5 mg/dL) 2
• History of cerebral atherosclerosis (may increase recurrent stroke risk) 5

Timing of Initiation After Stroke

The risk of hemorrhagic transformation must be balanced against the risk of recurrent stroke. Recommended timing based on stroke severity:

• TIA: Start 1 day after event
• Mild stroke: >3 days post-stroke
• Moderate stroke: >6-8 days post-stroke
• Severe stroke: >12-14 days post-stroke 2

For patients at high risk of hemorrhagic conversion, delaying initiation beyond 14 days is reasonable 1

Contraindications

Eliquis is contraindicated in:

• Active pathological bleeding
• Severe hypersensitivity reactions to apixaban
• Moderate to severe mitral stenosis
• Mechanical heart valves 2, 4

Drug Interactions

• Combined P-gp and strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir): Reduce apixaban dose by 50% if taking 5mg twice daily; avoid if already on reduced dose of 2.5mg twice daily 4
• Antiplatelet agents: Significantly increases bleeding risk 4

Risk of Thrombotic Events After Discontinuation

Premature discontinuation of apixaban increases the risk of thrombotic events. Do not stop taking apixaban without consulting your healthcare provider 4.

Special Populations

• Renal impairment: For patients with end-stage renal disease or on dialysis, warfarin or dose-adjusted apixaban may be reasonable 1
• Cerebral atherosclerosis: Patients with cerebral atherosclerotic lesions may have a higher rate of major events (4.6% vs 1.7%) 5

Monitoring and Follow-up

• No routine coagulation monitoring required
• Monitor renal function at least annually, more frequently if impaired
• Assess medication adherence at each follow-up visit 2

Reversal of Anticoagulant Effect

• Andexanet alfa is available to reverse anti-factor Xa activity
• Anticoagulant effect persists for at least 24 hours after the last dose
• Activated charcoal may reduce absorption if taken soon after ingestion
• Hemodialysis does not significantly impact apixaban levels 4

Comparative Effectiveness

• Apixaban has been shown to be superior to warfarin in preventing stroke and systemic embolism 6
• Real-world studies show apixaban has similar effectiveness to dabigatran and rivaroxaban in reducing thromboembolic events 3
• Apixaban and edoxaban demonstrate lower mortality risk after ischemic stroke compared to other DOACs 7

Common Pitfalls to Avoid

1. Abrupt discontinuation: Never stop apixaban suddenly without medical guidance
2. Inadequate dose adjustment: Failure to reduce dose in patients with ≥2 risk factors (age ≥80, weight ≤60kg, creatinine ≥1.5mg/dL)
3. Combining with antiplatelet therapy without specific indication
4. Starting too early after severe stroke: Increases risk of hemorrhagic transformation
5. Missing doses: Short half-life means missed doses quickly reduce protection

Remember that while Eliquis carries bleeding risks, it provides significant benefits in stroke prevention for appropriate patients, with a more favorable safety profile than warfarin.