What is the recommended management for a patient with a history of lupus who is already on Eliquis (apixaban)?

Management of Lupus Patients on Apixaban (Eliquis)

For patients with a history of lupus who are already on Eliquis (apixaban), continuation of therapy is recommended with careful monitoring for thrombotic and bleeding complications, while maintaining hydroxychloroquine as the cornerstone of lupus management.

Rationale for Continuing Apixaban in Lupus Patients

• Apixaban is indicated for the treatment of pulmonary embolism, deep vein thrombosis, and reduction in the risk of recurrent DVT and PE following initial therapy 1
• In patients with SLE and antiphospholipid syndrome (APS), long-term anticoagulation is effective for secondary prevention of thrombosis 2, 3
• The standard dose of apixaban is 5 mg twice daily for most patients, with dose reduction to 2.5 mg twice daily for patients with at least two of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 1

Special Considerations for Lupus Patients on Anticoagulation

• Hydroxychloroquine should be maintained as the cornerstone of SLE treatment for all lupus patients, including those on anticoagulation, as it reduces disease flares and has protective effects against thrombosis 2, 3
• Lupus patients with antiphospholipid antibodies have increased risk of thrombotic events and may benefit from continued anticoagulation 2
• Direct oral anticoagulants (DOACs) like apixaban may interfere with lupus anticoagulant testing, potentially causing false positive results 4, 5
• If lupus anticoagulant testing is needed while on apixaban, specialized techniques such as DOAC-Stop (activated charcoal) may be used to remove the drug from plasma samples for accurate testing 4, 5

Monitoring Recommendations

• Regular monitoring of disease activity using validated indices (SLEDAI, BILAG) is essential for lupus patients on anticoagulation 2
• Monitor for signs of bleeding, which is the most significant risk with apixaban therapy 1
• If temporary interruption of apixaban is needed for surgery or procedures:
  • Discontinue apixaban at least 48 hours prior to procedures with moderate/high bleeding risk
  • Discontinue at least 24 hours prior to procedures with low bleeding risk 1
• Resume apixaban as soon as adequate hemostasis has been established 1

Drug Interactions and Precautions

• For patients receiving apixaban 5 mg twice daily who require concomitant therapy with combined P-glycoprotein (P-gp) and strong CYP3A4 inhibitors, reduce the dose by 50% 1
• In patients already taking 2.5 mg twice daily, avoid coadministration with combined P-gp and strong CYP3A4 inhibitors 1
• Estrogen-containing medications increase the risk of thrombosis in lupus patients with antiphospholipid antibodies and should be used with caution 2, 3

Important Caveats

• A recent randomized trial comparing rivaroxaban (another DOAC) to warfarin in APS with triple antibody positivity was prematurely terminated due to excess thromboembolic events in the DOAC arm 2
• While specific studies on apixaban in lupus-associated APS are limited, caution should be exercised when using DOACs in patients with triple-positive antiphospholipid syndrome 2
• If the patient has lupus anticoagulant positivity, monitoring anticoagulation with INR may be unreliable as lupus anticoagulants can influence prothrombin times and lead to INRs that do not accurately reflect the true level of anticoagulation 6

Pregnancy Considerations

• In pregnant patients with SLE and antiphospholipid syndrome, combined unfractionated or low molecular weight heparin and aspirin are recommended instead of apixaban 2
• Apixaban should be discontinued and switched to appropriate pregnancy-compatible anticoagulation if pregnancy is planned or confirmed 2, 3