Is there a contraindication between Journavx and Eliquis (apixaban)?

Contraindications Between Journavx and Eliquis (Apixaban)

There is no established contraindication between Journavx and apixaban (Eliquis), but caution should be exercised due to potential drug interactions that could affect apixaban's plasma concentration.

Mechanism of Potential Interaction

Apixaban (Eliquis) is metabolized primarily through:

• CYP3A4 pathway
• P-glycoprotein (P-gp) transport system

The main concerns with drug interactions involving apixaban are:

1. Pharmacokinetic interactions:

   • Medications that strongly inhibit both CYP3A4 and P-gp can significantly increase apixaban plasma concentrations, increasing bleeding risk 1
   • Medications that induce CYP3A4 can decrease apixaban concentrations, potentially reducing efficacy

2. Pharmacodynamic interactions:

   • Concurrent use with other medications affecting hemostasis (antiplatelet agents, NSAIDs) increases bleeding risk 2

Assessment of Journavx Interaction Risk

When evaluating the potential interaction between Journavx and apixaban:

• If Journavx is a strong dual inhibitor of CYP3A4 and P-gp:

  • Consider alternative medication
  • If combination necessary, reduce apixaban dose by 25% 1

• If Journavx is a CYP3A4 inducer:

  • Monitor for reduced anticoagulant effect
  • Consider alternative anticoagulant if strong induction expected

General Contraindications for Apixaban

According to guidelines, absolute contraindications for apixaban include:

• Severe renal impairment (CrCl <25 mL/min) 1
• Active/clinically significant liver disease (ALT/AST >2x ULN; total bilirubin >1.5x ULN) 1
• Strong dual inhibitors/inducers of CYP3A4 and P-glycoprotein 1
• Active major bleeding

Management Recommendations

If concurrent use of Journavx and apixaban is necessary:

1. Evaluate bleeding risk:

   • Assess patient's renal function, hepatic function, age, weight, and concomitant medications
   • Consider bleeding history and risk factors

2. Consider dose adjustment:

   • If Journavx has moderate inhibitory effects on CYP3A4 or P-gp, consider reducing apixaban dose by 25% 1
   • Standard dose reduction criteria for apixaban: reduce to 2.5mg twice daily if patient has at least two of: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 2

3. Monitoring:

   • Regular assessment for bleeding signs
   • Periodic evaluation of renal and hepatic function
   • Monitor for signs of thrombosis if reduced efficacy is a concern

Alternative Approaches

If the interaction risk is deemed significant:

1. Alternative anticoagulants:

   • Consider LMWH which has fewer drug interactions 2
   • Consider VKA (warfarin) with appropriate monitoring

2. Timing separation:

   • For some P-gp interactions, administering apixaban at least 2 hours before the interacting medication may help reduce interaction risk 1

Perioperative Considerations

If invasive procedures are needed while on this combination:

• For low bleeding risk procedures: interrupt apixaban 24 hours before procedure 1
• For high bleeding risk procedures: interrupt apixaban 3 days before procedure 1
• Resume apixaban at least 6 hours after procedure completion if hemostasis is achieved 1

The decision to use Journavx with apixaban should be based on a careful assessment of the specific properties of Journavx, the patient's clinical characteristics, and the availability of alternative treatment options.