What are the thromboprophylaxis options for a patient with atrial fibrillation (AFib) who cannot take apixaban (Eliquis)?

Thromboprophylaxis Options for Patients with Atrial Fibrillation Unable to Take Apixaban

For patients with atrial fibrillation who cannot take apixaban, alternative oral anticoagulants such as dabigatran or rivaroxaban should be considered as first-line alternatives, followed by adjusted-dose warfarin, or in cases where all oral anticoagulants are contraindicated, antiplatelet therapy with aspirin plus clopidogrel may be considered. 1

Alternative Oral Anticoagulants

Direct Thrombin Inhibitor

• Dabigatran (150 mg twice daily) is recommended as an effective alternative to apixaban for stroke prevention in non-valvular atrial fibrillation 1
• Dose reduction to 110 mg twice daily should be considered for:
  • Elderly patients aged ≥80 years 1
  • Patients with high bleeding risk (HAS-BLED score ≥3) 1
  • Patients with moderate renal impairment (CrCl 30-49 mL/min) 1
  • Patients taking interacting drugs like verapamil 1
• Dabigatran is contraindicated in patients with mechanical heart valves due to increased risk of thromboembolism 2, 1

Factor Xa Inhibitor

• Rivaroxaban (20 mg once daily) can be used as an alternative to apixaban 1
• Dose reduction to 15 mg once daily is recommended for:
  • Patients with high bleeding risk (HAS-BLED score ≥3) 1
  • Patients with moderate renal impairment (CrCl 30-49 mL/min) 1

Traditional Anticoagulant Option

• Adjusted-dose warfarin (INR 2-3) remains an effective option for stroke prevention in AF when NOACs cannot be used 1
• Warfarin is the only recommended option for patients with:
  • Mechanical heart valves 1
  • Severe renal impairment (CrCl <30 mL/min) or dialysis 1
• Regular INR monitoring is required at least weekly during initiation and monthly when stable 1

Options for Patients Who Cannot Take Any Oral Anticoagulant

Antiplatelet Therapy

• For patients who refuse or cannot take any oral anticoagulant, combination therapy with aspirin (75-100 mg) plus clopidogrel (75 mg) daily may be considered 1
• Single antiplatelet therapy with aspirin 75-325 mg daily is less effective but may be used when dual antiplatelet therapy poses excessive bleeding risk 1
• Note that antiplatelet therapy carries a bleeding risk similar to oral anticoagulation but with less effective stroke prevention 1

Special Considerations

Renal Function

• Regular assessment of renal function is essential when using NOACs 1
• For patients with severe renal impairment (CrCl <30 mL/min), NOACs are generally not recommended 1
• In dialysis-dependent patients, adjusted-dose warfarin may be considered 1

Bleeding Risk Assessment

• The HAS-BLED score should be used to identify and address modifiable bleeding risk factors 1
• High HAS-BLED score (≥3) indicates increased bleeding risk requiring more frequent monitoring but should not exclude patients from anticoagulation 1

Peri-Procedural Management

• For patients requiring cardioversion, oral anticoagulation should be continued for at least 3 weeks before and 4 weeks after the procedure 1
• For patients undergoing procedures requiring interruption of anticoagulation, bridging therapy with unfractionated heparin or low-molecular-weight heparin should be considered based on individual stroke and bleeding risks 1

Clinical Pitfalls to Avoid

• Do not abruptly discontinue anticoagulation without a transition plan, as this increases thrombotic risk 1, 3
• Do not use NOACs in patients with mechanical heart valves 1, 2
• Avoid using reduced doses of NOACs unless specifically indicated by approved criteria 4
• Remember that antiplatelet therapy carries similar bleeding risk to oral anticoagulation but with less effective stroke prevention 1