What is the recommended dose of apixaban for a patient with Non-ST-Elevation Myocardial Infarction (NSTEMI) post-PerCutaneous Coronary Intervention (PCI) requiring anticoagulation?

Apixaban Dosing for NSTEMI Post-PCI Requiring Anticoagulation

For patients with NSTEMI post-PCI requiring anticoagulation, apixaban is not part of standard therapy unless there is a specific indication for anticoagulation, such as atrial fibrillation. 1

Standard Antithrombotic Therapy for NSTEMI Post-PCI

Antiplatelet Therapy

• For all NSTEMI patients post-PCI, dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor is the standard of care for at least 12 months 2
• Aspirin should be given at an initial dose of 162-325 mg (non-enteric formulation), followed by a maintenance dose of 81 mg daily (preferred over higher doses) 3, 2
• Clopidogrel should be administered with a loading dose of 300-600 mg if not previously on therapy, followed by 75 mg daily for at least 12 months 2

Anticoagulant Therapy During Hospitalization

• For patients with NSTEMI during initial hospitalization, anticoagulation options include:
  • Enoxaparin: 1 mg/kg SC every 12 hours (reduce to 1 mg/kg once daily if CrCl <30 mL/min) 2
  • Bivalirudin: 0.10 mg/kg loading dose followed by 0.25 mg/kg per hour 2
  • Fondaparinux: 2.5 mg SC daily 2
  • UFH: Initial loading dose of 60 IU/kg (maximum 4000 IU) with initial infusion of 12 IU/kg per hour 2

Apixaban Dosing When Anticoagulation is Indicated

When a patient with NSTEMI post-PCI has a specific indication for anticoagulation (such as atrial fibrillation), the following approach is recommended:

Triple Therapy Period (Short-Term)

• Triple therapy (oral anticoagulant + DAPT) should be kept as short as possible (typically 1 week or until hospital discharge) to minimize bleeding risk 4, 5
• During this period, if apixaban is used:
  • Standard dosing of apixaban for atrial fibrillation should be used (5 mg twice daily or 2.5 mg twice daily if the patient meets at least two of the following criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL) 6, 5

Dual Therapy Period (Intermediate)

• After the initial triple therapy period, transition to dual therapy with apixaban plus a single antiplatelet agent (preferably clopidogrel 75 mg daily) for up to 12 months 4, 5
• Maintain standard apixaban dosing as above 6

Long-Term Therapy

• After 12 months, discontinue antiplatelet therapy and continue apixaban monotherapy at standard dosing 4, 5

Special Considerations

• Bleeding risk assessment is crucial when determining the duration of triple therapy 5
• For patients at high bleeding risk, consider shortening triple therapy to the absolute minimum or avoiding it altogether by using dual therapy (apixaban plus clopidogrel) from the outset 6, 5
• For patients at high thrombotic risk with acceptable bleeding risk, triple therapy may be extended up to 1 month 5

Common Pitfalls to Avoid

• Continuing triple therapy for too long, which significantly increases bleeding risk without providing additional ischemic protection 6, 5
• Using reduced doses of apixaban without appropriate indications, which may lead to inadequate stroke prevention 6
• Failing to reassess the need for continued antiplatelet therapy at regular intervals 5
• Using prasugrel or ticagrelor as part of triple therapy, which carries higher bleeding risk than clopidogrel 5