Can apixaban (Eliquis) cause thrombocytopenia?

From the Guidelines

Eliquis (apixaban) does not typically lower platelet levels. Eliquis is an anticoagulant medication that works by inhibiting Factor Xa, which prevents blood clot formation by reducing the production of thrombin. Unlike some other blood thinners, Eliquis does not directly affect platelet count or function. It works in the coagulation cascade rather than on platelets themselves. The study comparing CASSINI and AVERT studies 1 provides insight into the effects of apixaban on patients, but it does not specifically address the impact of apixaban on platelet levels. However, it does report on major bleeding (MB) and clinically relevant non-major bleeding (CRNMB) events, which can be related to platelet function. According to the study, the rates of MB and CRNMB were relatively low, with 10/288 (3.5%) and 21/288 (7.3%) for apixaban, respectively. If you're taking Eliquis and experiencing low platelet counts (thrombocytopenia), this is likely unrelated to the medication and should be evaluated by a healthcare provider promptly. While rare cases of drug-induced thrombocytopenia have been reported with Eliquis, these are extremely uncommon. Regular blood monitoring is not routinely required for patients taking Eliquis, unlike with warfarin, but your doctor may recommend periodic blood tests to check various parameters including platelet counts, especially if you have other medical conditions or are taking additional medications. Some key points to consider when evaluating the risk of bleeding with Eliquis include:

• The number needed to harm (NNH) for apixaban was 59, indicating that 59 patients would need to be treated with apixaban to cause one additional major bleeding event compared to placebo 1.
• The rates of on-treatment major bleeding were relatively low, with 6/288 (2.1%) for apixaban 1.
• The study did not report a significant impact of apixaban on platelet counts, but it did report on bleeding events, which can be related to platelet function.

From the FDA Drug Label

Less common adverse reactions in apixaban-treated patients undergoing hip or knee replacement surgery occurring at a frequency of ≥0.1%: thrombocytopenia (including platelet count decreases) The FDA drug label indicates that thrombocytopenia (including platelet count decreases) is a less common adverse reaction in apixaban-treated patients, which suggests that Eliquis (apixaban) can lower platelet levels in some patients 2.

• Key points:
  • Thrombocytopenia is a less common adverse reaction
  • Platelet count decreases have been reported
  • Eliquis may lower platelet levels in some patients

From the Research

Eliquis and Platelet Levels

• The effect of Eliquis (apixaban) on platelet levels is not explicitly stated in most studies, but some provide insight into its impact on platelet count and activation.
• A study published in 2022 3 found that apixaban therapy led to normalized platelet counts in patients with heparin-induced thrombocytopenia (HIT).
• Another study from 2019 4 reported a case where apixaban was used to treat HIT, and the patient's platelet count remained stable throughout the therapy.
• However, a study from 2017 5 found that apixaban did not alter platelet reactivity in patients with atrial fibrillation, as measured by whole blood aggregometry.
• In vitro studies, such as one published in 2010 6, have shown that apixaban can inhibit tissue-factor induced human platelet aggregation, but this may not directly translate to an effect on platelet levels in clinical settings.

Clinical Implications

• The available evidence suggests that apixaban may not have a significant impact on platelet levels in most patients, but it may be effective in treating conditions like HIT, where platelet count is a concern.
• More research is needed to fully understand the effects of apixaban on platelet levels and to determine its safety and efficacy in patients with thrombocytopenia or other platelet-related disorders, as noted in a study from 2020 7.