What is the appropriate regimen for patients requiring anticoagulation and antiplatelet therapy with Eliquis (apixaban) and aspirin?

Appropriate Regimen for Patients Requiring Anticoagulation with Apixaban and Antiplatelet Therapy

For most patients requiring both anticoagulation and antiplatelet therapy, dual therapy with apixaban plus a single antiplatelet agent (preferably clopidogrel) is recommended over triple therapy to reduce bleeding risk while maintaining efficacy for preventing thrombotic events. 1

Decision Algorithm Based on Clinical Scenario

1. Patients with Atrial Fibrillation (AF) and Stable Ischemic Heart Disease (SIHD)

• No history of ACS, no prior revascularization: Stop aspirin completely and use apixaban alone 1, 2
• Prior PCI:
  • <6 months since PCI: Stop aspirin, continue clopidogrel, start apixaban 1, 2
  • 6-12 months since PCI: Continue either aspirin or clopidogrel (preferably clopidogrel) until 1 year post-PCI, along with apixaban 1

  • 12 months since PCI: Stop all antiplatelet therapy and use apixaban alone 1, 2

• Prior CABG:
  • <1 year post-CABG: Continue low-dose aspirin (<100 mg daily) with apixaban 1, 2

  • 1 year post-CABG: Stop aspirin and use apixaban alone 1, 2

2. Patients with AF and Recent Acute Coronary Syndrome (ACS)

• <12 months since ACS: Stop aspirin, continue P2Y12 inhibitor (preferably clopidogrel), and start apixaban 1, 2
• >12 months since ACS: Stop all antiplatelet therapy and use apixaban alone 1, 2

3. Patients with AF Undergoing New PCI

• During hospitalization: Use low-dose aspirin (81mg) for the duration of hospitalization 1
• At discharge:
  • Standard approach: Stop aspirin, continue P2Y12 inhibitor (preferably clopidogrel), use apixaban 1
  • For patients at high thrombotic risk and low bleeding risk: Consider aspirin (81mg) for up to 30 days post-PCI 1

Apixaban Dosing

• Standard dose: 5mg twice daily 1, 3
• Reduced dose: 2.5mg twice daily if patient meets at least 2 of the following criteria 1, 3, 4:
  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL

Important Considerations

• The combination of antiplatelet therapy with anticoagulation significantly increases bleeding risk 5, 6
• Triple therapy (apixaban + dual antiplatelet therapy) should be avoided or minimized in duration whenever possible 1
• For patients on vitamin K antagonists (VKAs), target INR should be at the lower end of the therapeutic range (2.0-2.5) when combined with antiplatelet therapy 1
• Radial access is preferred for PCI procedures to minimize bleeding risk 1
• Proton pump inhibitors should be considered for patients on combination therapy to reduce gastrointestinal bleeding risk 1, 7

Monitoring and Follow-up

• Regular assessment for signs of bleeding is essential 2
• Reassess the need for continued antiplatelet therapy at each follow-up visit 1, 2
• For patients who develop major bleeding, appropriate measures should be initiated to control bleeding, including consideration of reversal agents if necessary 1

Common Pitfalls to Avoid

1. Continuing triple therapy (apixaban + dual antiplatelet therapy) beyond the necessary duration
2. Failing to transition to apixaban monotherapy after the appropriate time period
3. Using inappropriate apixaban dosing when combined with antiplatelet therapy
4. Not considering bleeding risk when selecting therapy
5. Continuing antiplatelet therapy indefinitely without reassessment

By following this algorithm, clinicians can optimize the balance between preventing thrombotic events and minimizing bleeding risk in patients requiring both anticoagulation with apixaban and antiplatelet therapy.