Can a proton pump inhibitor (PPI) be started in a patient taking Eliquis (apixaban)?

Proton Pump Inhibitors with Eliquis (Apixaban)

A proton pump inhibitor (PPI) should be considered when taking Eliquis (apixaban) based on your individual gastrointestinal bleeding risk factors. 1, 2

Recommendations for PPI Use with Eliquis

When to Use a PPI with Eliquis

• PPIs are recommended for patients taking anticoagulants (like Eliquis) who are at increased risk of gastrointestinal bleeding 1, 2
• Risk assessment should be performed before starting a PPI in patients on anticoagulants 1
• PPIs should be considered with single anticoagulant therapy (like Eliquis alone) based on individual patient GI bleeding risk 1

High-Risk Patients Who Should Receive a PPI

Patients taking Eliquis with any of these risk factors should receive a PPI:

• History of upper GI bleeding 1, 2
• Advanced age (especially >60 years) 1, 2
• Concurrent use of multiple antithrombotic agents 1
• Concomitant use of NSAIDs or steroids 1, 2
• Helicobacter pylori infection 1, 2
• Severe medical comorbidities 1

Low-Risk Patients

• Routine PPI use is not recommended for patients at low risk of gastrointestinal bleeding who have limited potential benefit from prophylactic therapy 1

Clinical Decision Algorithm

1. Assess bleeding risk factors:

   • Prior GI bleeding history? (highest risk factor) 1
   • Age >60 years? 1
   • Taking other medications that increase bleeding risk (NSAIDs, steroids, second antiplatelet)? 1
   • Multiple antithrombotics or dual antiplatelet therapy? 1, 3
   • Known H. pylori infection? 1
   • Severe comorbidities? 1

2. Decision pathway:

   • If any high-risk factors present: Start PPI 1
   • If multiple moderate risk factors: Consider PPI 1, 2
   • If low risk (no risk factors): PPI not routinely recommended 1

Important Considerations

Benefits of PPI with Anticoagulants

• PPIs markedly reduce the likelihood of upper GI bleeding in patients on antithrombotic therapy 1
• PPIs are particularly beneficial for patients with multiple risk factors for GI bleeding 2, 3

Potential Concerns with Long-term PPI Use

• Long-term PPI use has been associated with potential adverse effects including:
  • Clostridium difficile infection 1, 4
  • Pneumonia 1, 5
  • Nutrient malabsorption 2
  • Potential cardiovascular effects (though evidence is not from randomized controlled trials) 5

Monitoring and Follow-up

• Regularly reassess the need for continued PPI therapy 1
• Document the specific indication for PPI use 1
• Consider histamine-2 receptor antagonists as an alternative in certain patients with lower risk 5
• Be aware that discontinuation of long-term PPI may lead to rebound acid hypersecretion and transient upper GI symptoms 1

Special Situations

• Patients with Barrett's esophagus, severe erosive esophagitis, or idiopathic pulmonary fibrosis should generally continue PPI therapy regardless of anticoagulant use 1
• Patients with a history of peptic ulcer bleeding should definitely receive a PPI while on Eliquis 1