Does a diabetic patient with atrial fibrillation (AFib) on Eliquis (apixaban) require aspirin for primary prevention of atherosclerotic cardiovascular disease (ASCVD) with a 16% risk?

From the Guidelines

For a diabetic patient with atrial fibrillation who is already on Eliquis (apixaban), adding aspirin for primary prevention is generally not recommended, even with an ASCVD risk of 16%. The patient is already receiving anticoagulation with Eliquis for stroke prevention related to atrial fibrillation, and adding aspirin would significantly increase bleeding risk without providing substantial additional cardiovascular benefit, as supported by the most recent guidelines 1. The combination of a direct oral anticoagulant (DOAC) like Eliquis with aspirin creates a "dual antithrombotic" state that approximately doubles bleeding risk compared to anticoagulation alone.

Current guidelines have moved away from routine aspirin use for primary prevention, even in diabetic patients, as the bleeding risks often outweigh the benefits, as seen in studies such as the ASCEND trial 1. Instead, focus should be placed on optimizing other cardiovascular risk factors such as:

• Blood pressure control
• Lipid management with statins
• Diabetes management
• Smoking cessation if applicable
• Lifestyle modifications

If the patient has documented coronary artery disease or other atherosclerotic vascular disease (making this secondary rather than primary prevention), then the risk-benefit calculation might change, but for primary prevention in a patient already anticoagulated, aspirin should be avoided, as recommended in the 2024 standards of care in diabetes 1. The most recent evidence suggests that aspirin therapy for primary prevention may be considered in the context of shared decision-making, which carefully weighs the cardiovascular benefits with the fairly comparable increase in risk of bleeding, but this should be done with caution and careful consideration of the individual patient's risk factors and bleeding risk 1.

From the FDA Drug Label

In AVERROES, patients with nonvalvular atrial fibrillation thought not to be candidates for warfarin therapy were randomized to treatment with apixaban 5 mg orally twice daily (or 2. 5 mg twice daily in selected patients) or aspirin 81 to 324 mg once daily.

The patient is already on Eliquis (apixaban) for atrial fibrillation, and the question is about the need for aspirin for primary prevention of ASCVD with a risk of 16%.

• The provided drug label does not directly address the use of aspirin for primary prevention of ASCVD in patients with atrial fibrillation who are already on apixaban.
• The AVERROES study compared apixaban to aspirin for preventing stroke or systemic embolism in patients with nonvalvular atrial fibrillation, but it does not provide information on the use of aspirin for primary prevention of ASCVD.
• Therefore, based on the provided drug label, no conclusion can be drawn about the need for aspirin in this patient. 2

From the Research

Ascvd Risk and Aspirin Therapy

• The patient's 10-year ASCVD risk is 16%, which is considered high 3.
• Diabetic patients with a high ASCVD risk (>10%) are generally recommended for aspirin therapy if bleeding risk is felt to be low 3.
• However, the patient is already on Eliquis (apixaban) for atrial fibrillation, which may affect the need for aspirin therapy.

Apixaban and Aspirin Interaction

• Studies have shown that apixaban has similar benefits on reducing stroke, decreasing mortality, and causing less intra-cranial bleeding than warfarin in patients with and without diabetes 4, 5.
• There is no direct evidence on the interaction between apixaban and aspirin in diabetic patients with atrial fibrillation.
• However, a study comparing apixaban with aspirin in patients with atrial fibrillation found 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 5.

Diabetes and Atrial Fibrillation Management

• Diabetes is associated with an increased risk of developing atrial fibrillation and influences the management and prognosis of atrial fibrillation 6, 7.
• The presence of diabetes in patients with atrial fibrillation is associated with increased symptom burden and increased cardiovascular and cerebrovascular mortality 7.
• The management of atrial fibrillation in diabetic patients requires careful consideration of the risks and benefits of different treatment options, including anticoagulation and antiplatelet therapy 6.