Is Eliquis (apixaban) used for patients post coronary stent?

Apixaban (Eliquis) Use After Coronary Stent Placement

Apixaban (Eliquis) is not recommended as standard therapy for patients after coronary stent placement unless they also have atrial fibrillation or another indication for oral anticoagulation. When used in this context, it must be carefully managed as part of a specific antithrombotic regimen.

Standard Post-Coronary Stent Antithrombotic Therapy

For most patients after coronary stent placement without atrial fibrillation:

• The standard regimen consists of dual antiplatelet therapy (DAPT):
  • Aspirin 75-100 mg daily (indefinitely)
  • P2Y12 inhibitor (typically clopidogrel 75 mg daily) for a duration based on stent type:
    • At least 1 month for bare metal stents
    • At least 6 months for drug-eluting stents
    • Up to 12 months in patients without high bleeding risk 1

Apixaban Use in Special Populations After Coronary Stent

Patients with Atrial Fibrillation Undergoing PCI

For patients with atrial fibrillation who receive coronary stents, recent evidence supports:

1. Dual therapy approach (preferred):

   • Apixaban + single antiplatelet (usually clopidogrel)
   • Less bleeding risk than triple therapy while maintaining efficacy 2

2. Triple therapy approach (short duration):

   • Apixaban + aspirin + clopidogrel
   • Used for shortest necessary duration (typically during hospitalization or up to 1 month) 3, 2
   • Then transition to dual therapy

Dosing Considerations

• Standard apixaban dose: 5 mg twice daily
• Reduced dose (2.5 mg twice daily) for patients meeting ≥2 criteria:
  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL 4

Important Cautions

1. Increased bleeding risk: The APPRAISE-2 trial was terminated early due to increased bleeding when apixaban was added to standard antiplatelet therapy in post-ACS patients without a counterbalancing reduction in ischemic events 5, 6

2. Drug interactions:

   • Concomitant use with antiplatelet agents increases bleeding risk
   • Dose adjustment needed with strong CYP3A4/P-gp inhibitors 5

3. Timing of discontinuation before procedures:

   • For low bleeding risk procedures: stop 2 days before
   • For high bleeding risk procedures: stop 3 days before (longer with renal impairment) 3

Current Practice Recommendations

For patients requiring both anticoagulation and antiplatelet therapy after coronary stenting:

1. Assess bleeding and thrombotic risks individually

2. Duration of triple therapy should be minimized:

   • Consider discontinuing aspirin at discharge in most patients
   • Continue dual therapy (apixaban + clopidogrel) for 12 months
   • Then transition to anticoagulant monotherapy 2

3. Consider adding a proton pump inhibitor to reduce gastrointestinal bleeding risk

Conclusion

While apixaban is being studied in patients with coronary stents (e.g., AUGUSTUS trial), it is not standard therapy post-stent unless the patient has atrial fibrillation or another indication for anticoagulation. When used in these special populations, careful management of the antithrombotic regimen is essential to balance thrombotic and bleeding risks.