When should a patient be on Eliquis (apixaban) and aspirin?

From the Guidelines

Patients with atrial fibrillation and acute coronary syndrome or those undergoing percutaneous coronary intervention should be considered for dual therapy with Eliquis (apixaban) 5mg twice daily and aspirin 81-100mg daily for a minimum of 6 months, with a maximum duration of 12 months, as supported by the AUGUSTUS trial 1.

Key Considerations

• The decision to extend or modify dual therapy should be individualized based on the patient's risk of thromboembolic events and bleeding complications, taking into account the results of studies such as the PIONEER AF-PCI and RE-DUAL PCI trials 1.
• For patients deemed to be at high risk of bleeding, discontinuation of single antiplatelet therapy (SAPT) before the recommended duration can be considered, but the relative risks of stent thrombosis versus bleeding need to be considered 1.
• The combination of OAC with antiplatelet agents, such as aspirin, without an adequate indication occurs frequently in clinical practice, but bleeding events are more common when antithrombotic agents are combined, and no clear benefit has been observed in terms of prevention of stroke or death 1.

Important Factors

• The patient's risk of thromboembolic events and bleeding complications should be carefully assessed, as dual therapy with apixaban and aspirin may increase the risk of bleeding, as seen in the AUGUSTUS trial 1.
• The characteristics and morphology of the vessel, lesion, and stent location may influence decisions regarding DAPT duration and the safety of shortening it, irrespective of the type of stent used 1.
• Cost and patient preference may be taken into consideration when making decisions regarding choice of therapy, as highlighted in the 2020 ACC expert consensus decision pathway 1.

From the FDA Drug Label

Concomitant use of drugs affecting hemostasis increases the risk of bleeding. These include aspirin and other antiplatelet agents, other anticoagulants, heparin, thrombolytic agents, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and nonsteroidal anti-inflammatory drugs (NSAIDs)

The patient should be on Eliquis (apixaban) and aspirin when the benefit of concomitant use outweighs the increased risk of bleeding. However, the FDA drug label does not provide specific guidance on when to use apixaban and aspirin together. The decision to use concomitant therapy should be made on a case-by-case basis, considering the individual patient's risk factors for bleeding and thromboembolism.

• The patient's medical history, including any history of bleeding or thromboembolic events, should be taken into account.
• The patient's current medications, including any medications that may increase the risk of bleeding, should be considered.
• The patient's renal function and liver function should be evaluated, as these may affect the metabolism and clearance of apixaban.
• The patient should be closely monitored for signs and symptoms of bleeding, and the dose of apixaban and aspirin should be adjusted as needed to minimize the risk of bleeding 2 2.

From the Research

Patient Eligibility for Eliquis (Apixaban) and Aspirin

The decision to prescribe Eliquis (apixaban) and aspirin to a patient depends on various factors, including the presence of non-valvular atrial fibrillation, coronary artery disease, and the patient's risk of stroke and bleeding.

• Patients with non-valvular atrial fibrillation who undergo percutaneous coronary intervention (PCI) may benefit from dual antithrombotic therapy with apixaban and aspirin, as it reduces the risk of major bleeding and intracranial hemorrhage compared to triple antithrombotic therapy 3.
• The combination of apixaban and aspirin may be preferred for patients at high ischemic risk, as adding aspirin for up to 4 weeks can prevent atherothrombotic events 4.
• Patients with non-valvular atrial fibrillation and concomitant coronary/peripheral artery disease may benefit from apixaban, as it is associated with lower rates of stroke/systemic embolism, major bleeding, and composite of stroke/myocardial infarction/all-cause mortality compared to warfarin 5.

Risk Stratification

Risk stratification is essential to determine the best antithrombotic regimen for patients with non-valvular atrial fibrillation.

• Patients with low stroke risk (about 1% per year) may be treated with aspirin, while those with moderate (about 3% per year) or high (about 6% per year) stroke risk may benefit from anticoagulation therapy with apixaban or warfarin 6.
• The CHA2DS2-VASc score can be used to assess the patient's stroke risk, with higher scores indicating a greater risk of stroke 3, 4.

Bleeding Risk

The risk of bleeding is a significant concern when prescribing antithrombotic therapy.

• Apixaban has been shown to reduce the risk of major bleeding and intracranial hemorrhage compared to warfarin 5, 7.
• The risk of bleeding should be carefully assessed and monitored in patients receiving apixaban and aspirin, particularly in those with impaired renal function or a history of bleeding 7.