Can Eliquis (Apixaban) cause thrombocytopenia?

From the Guidelines

Eliquis (apixaban) can cause thrombocytopenia, although it is considered a rare side effect, and patients should be monitored for symptoms of thrombocytopenia, especially during the initial period of treatment. Thrombocytopenia is a condition characterized by abnormally low platelet counts in the blood, which can increase the risk of bleeding. The mechanism behind apixaban-induced thrombocytopenia is not fully understood but may involve immune-mediated reactions or direct effects on platelet production. According to a study published in 2020 1, direct oral anticoagulants (DOAs) like apixaban have been proposed as a treatment option for heparin-induced thrombocytopenia (HIT), suggesting that apixaban may have a role in managing thrombocytopenia. However, the study also notes that the diagnosis of HIT should not be neglected, and confirmatory biological tests should be prescribed.

Some key points to consider:

• Patients taking Eliquis should be aware of symptoms that might indicate thrombocytopenia, including unusual bruising, petechiae (small red or purple spots on the skin), prolonged bleeding from cuts, nose bleeds, or blood in urine or stool.
• Regular blood count monitoring is advisable, especially during the initial period of treatment.
• If thrombocytopenia is suspected, healthcare providers may need to adjust the dosage or consider alternative anticoagulants.
• The risk of thrombocytopenia appears to be lower with direct oral anticoagulants like Eliquis compared to older anticoagulants like heparin, which is known to cause heparin-induced thrombocytopenia (HIT) 1.
• Any unexplained symptoms of bleeding while on Eliquis should prompt immediate medical attention.

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%:

• lymphatic system disorders: thrombocytopenia (including platelet count decreases)

• Thrombocytopenia is listed as a less common adverse reaction in apixaban-treated patients, occurring at a frequency of ≥0.1% 2.
• This indicates that Eliquis (Apixaban) can cause thrombocytopenia.

From the Research

Eliquis (Apixaban) and Thrombocytopenia

• Thrombocytopenia is a potential side effect of apixaban, as reported in several studies 3, 4.
• A case report published in 2017 described apixaban-induced thrombocytopenia as an uncommon but life-threatening side effect 4.
• Another study published in 2019 suggested that thrombocytopenia should be considered and monitored closely in patients taking apixaban for stroke prevention in atrial fibrillation 3.
• However, the incidence of thrombocytopenia associated with apixaban is not well-established and may be rare.
• In contrast, apixaban has been shown to be effective in preventing recurrent venous thromboembolism and major bleeding events compared to rivaroxaban 5.
• The use of apixaban compared to rivaroxaban was associated with a decreased risk of recurrent venous thromboembolism and major bleeding events in a retrospective population-based cohort analysis 5.

Comparison with Other Anticoagulants

• Apixaban is a direct oral anticoagulant (DOAC) that has been compared to other anticoagulants such as warfarin and rivaroxaban in terms of bleeding risk and efficacy 6, 5.
• The ARISTOTLE Trial found that apixaban was associated with a lower rate of intracranial hemorrhages and less adverse consequences following extracranial hemorrhage compared to warfarin 6.
• A study published in 2018 reviewed the available literature on extracranial and intracranial bleeding concerning apixaban and found that bleeding is an adverse event associated with a significant increase in morbidity and risk of death 6.

Clinical Implications

• Clinicians should be aware of the potential risk of thrombocytopenia associated with apixaban and monitor patients closely for signs of bleeding or thrombocytopenia 3, 4.
• The use of apixaban should be carefully considered in patients with a history of bleeding or thrombocytopenia, and alternative anticoagulants may be preferred in these cases.
• Further studies are needed to establish the incidence and risk factors for thrombocytopenia associated with apixaban 3, 4.