What is the interaction between Aspirin (acetylsalicylic acid) and Eliquis (apixaban)?

From the Guidelines

The interaction between Aspirin (acetylsalicylic acid) and Eliquis (apixaban) is that combining them increases the risk of bleeding events without a clear benefit in terms of stroke or death prevention, and therefore, this combination should only be used in selected patients with acute vascular disease.

Key Points

• The AVERROES trial demonstrated a lower rate of stroke or systemic embolism with apixaban compared with aspirin, with no significant difference in major bleeding 1.
• The combination of antiplatelet agents, such as aspirin, with anticoagulants, such as apixaban, should be avoided unless there is a clear indication, such as acute coronary syndromes 1.
• Apixaban has been shown to be a safe and efficacious alternative to aspirin in patients with nonvalvular atrial fibrillation deemed unsuitable for vitamin K antagonist therapy 1.
• The use of apixaban with aspirin is not recommended unless necessary, as it increases the risk of bleeding events without a clear benefit in terms of stroke or death prevention 1.

Clinical Implications

• In clinical practice, the combination of aspirin with apixaban should be used with caution and only in selected patients with acute vascular disease.
• Apixaban is a preferred alternative to aspirin in patients with nonvalvular atrial fibrillation, especially those deemed unsuitable for vitamin K antagonist therapy.
• The decision to use apixaban with or without aspirin should be based on individual patient risk factors and clinical judgment.

From the FDA Drug Label

1. 3 Anticoagulants and Antiplatelet Agents Coadministration of antiplatelet agents, fibrinolytics, heparin, aspirin, and chronic NSAID use increases the risk of bleeding APPRAISE-2, a placebo-controlled clinical trial of apixaban in high-risk, post-acute coronary syndrome patients treated with aspirin or the combination of aspirin and clopidogrel, was terminated early due to a higher rate of bleeding with apixaban compared to placebo. In ARISTOTLE, concomitant use of aspirin increased the bleeding risk on apixaban from 1.8% per year to 3.4% per year

The interaction between Aspirin (acetylsalicylic acid) and Eliquis (apixaban) is an increased risk of bleeding.

• Concomitant use of aspirin with apixaban increases the bleeding risk.
• Clinical trials, such as APPRAISE-2 and ARISTOTLE, have demonstrated a higher rate of bleeding with apixaban compared to placebo in patients treated with aspirin. 2

From the Research

Interaction between Aspirin and Eliquis (Apixaban)

The interaction between Aspirin (acetylsalicylic acid) and Eliquis (apixaban) has been studied in several clinical trials.

• The AVERROES trial compared apixaban with aspirin in patients with atrial fibrillation who were at increased risk of stroke and for whom vitamin K antagonists were unsuitable 3.
• The results showed that apixaban was associated with a significantly lower risk of stroke or systemic embolism than aspirin, without an increase in the risk of major bleeding 4, 3.
• The ARISTOTLE trial compared apixaban with warfarin in patients with atrial fibrillation, and found that apixaban reduced the risk of stroke or systemic embolism by 21% compared with warfarin 3.
• A subgroup analysis of the ARISTOTLE trial found that apixaban had similar beneficial effects on stroke or systemic embolism and major bleeding compared with warfarin, irrespective of concomitant aspirin use 5.
• Another study found that the rate of bleeding events was 3.8%/year with aspirin and 4.5%/year with apixaban, with no significant difference between the two groups 6.

Bleeding Risks

• The bleeding risks associated with apixaban and aspirin were similar, with no significant difference in the rate of major bleeding or clinically relevant non-major bleeding 6.
• The anatomic site of bleeding did not differ between therapies, and risk factors for bleeding common to apixaban and aspirin included use of non-study aspirin and a history of daily/occasional nosebleeds 6.
• Higher CHADS2 scores were associated with increasing rates of bleeding and stroke, but the balance between risks and benefits of apixaban compared with aspirin was favorable irrespective of baseline stroke risk 6.

Clinical Implications

• Apixaban is an important new option for use in patients with non-valvular atrial fibrillation to reduce the risk of stroke or systemic embolism 4.
• The choice of antithrombotic treatment for patients with atrial fibrillation should be based on individual patient characteristics and risk factors, including the risk of stroke and bleeding 7.