When to discontinue Eliquis (apixaban) after stent placement?

From the Guidelines

Patients with coronary stents who require anticoagulation, such as those with atrial fibrillation, should typically remain on dual antiplatelet therapy (DAPT) plus an anticoagulant like Eliquis for 1-6 months, followed by either an anticoagulant alone or with a single antiplatelet medication, as recommended by the most recent guidelines 1. The decision to discontinue Eliquis (apixaban) after stent placement should be made by your cardiologist based on your specific situation. For most patients, the triple therapy period is kept as short as possible—often just 1 month for newer-generation drug-eluting stents—to reduce bleeding risks, as supported by recent studies 1. After this initial period, patients usually continue on Eliquis plus a single antiplatelet (typically clopidogrel) for up to 12 months post-stent placement, in line with recommendations from the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention 2. Key considerations include:

• The risk of bleeding associated with concomitant anticoagulant and antiplatelet therapy, which is a significant concern in patients with atrial fibrillation or other indications for anticoagulation 1
• The importance of minimizing the duration of triple therapy to reduce bleeding risks, while also preventing stent thrombosis and stroke 1
• The need for regular follow-up appointments to monitor for bleeding issues and adjust the medication regimen as necessary to ensure the best possible outcomes for the patient's specific cardiovascular risk profile 1. Beyond 12 months, many patients can transition to Eliquis alone at the standard dose (5mg twice daily or 2.5mg twice daily for those meeting dose-reduction criteria), as this approach balances the need to prevent stent thrombosis and stroke with the need to minimize bleeding complications 1.

From the Research

Eliquis and Stent Placement

When considering when to get off Eliquis post-stent placement, several factors must be taken into account.

• The type of stent used: bare metal or drug-eluting stent 3
• The patient's risk of stroke and bleeding 4, 3
• The use of dual antiplatelet therapy (DAPT) and oral anticoagulation therapy 5, 6, 3

Dual Antiplatelet Therapy

Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is the standard of care after percutaneous coronary intervention (PCI) 6.

• Aspirin should be continued indefinitely, with a low dose preferred over higher doses 6
• A P2Y12 inhibitor should be administered for 12 months after PCI, unless the patient is at high risk for bleeding 6

Oral Anticoagulation Therapy

In patients requiring oral anticoagulation, the optimal antiplatelet regimen is controversial 3.

• For patients with a low risk of stroke, dual antiplatelet therapy alone may be sufficient 3
• For patients at moderate to high risk of stroke, dose-adjusted oral anticoagulation is needed 3
• The use of a bare metal stent, proton pump inhibitors, and tight control of the international normalized ratio (INR) can reduce the bleeding risk 3

Switching Between Antiplatelet Agents

There are no evidence-based guidelines for switching between P2Y12 receptor blockers 7.

• Cases of in-stent thrombosis have been reported when switching from ticagrelor to clopidogrel using a 300 mg clopidogrel loading dose 7
• Prospective trials are needed to determine the most appropriate strategy when switching between antiplatelet agents 7