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# Apixaban (Eliquis)
## Overview
Apixaban is a direct oral anticoagulant (DOAC) that selectively inhibits factor Xa. It has rapid onset, predictable pharmacokinetics, and does not require routine coagulation monitoring.
## Primary Indications
- Stroke prevention in non-valvular atrial fibrillation
- Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE)
- Prevention of recurrent DVT/PE
- Venous thromboembolism (VTE) prophylaxis following hip or knee replacement surgery
## Adult Dosing
**Atrial Fibrillation (Stroke Prevention):**
- Standard: 5 mg BID
- Dose reduction: 2.5 mg BID if ≥2 of: age ≥80 years, body weight ≤60 kg, serum creatinine ≥1.5 mg/dL
**DVT/PE Treatment:**
- 10 mg BID for 7 days, then 5 mg BID
**VTE Prophylaxis (Hip/Knee Replacement):**
- 2.5 mg BID, starting 12–24 hours post-surgery
- Hip: 35 days | Knee: 12 days
**Recurrent VTE Prevention:**
- 2.5 mg BID
## Pediatric Dosing
Dosing is weight-based and per local protocol. For treatment of VTE:
- **Weight-based dosing** (example range from trials):
- <10 kg: 1.5 mg BID
- 10–20 kg: 2.5 mg BID
- 20–40 kg: 5 mg BID
- ≥40 kg: 10 mg BID (initial), then 5 mg BID
Pediatric dosing should follow approved protocols and product labeling; adjustment for renal function and age is critical.
## Dose Adjustments
**Renal impairment:**
- Atrial fibrillation (CrCl 15–25 mL/min): use 2.5 mg BID if otherwise eligible for dose reduction
- Avoid if CrCl <15 mL/min or on dialysis (limited data)
- For VTE treatment, no adjustment needed unless CrCl <15 mL/min (avoid)
**Hepatic impairment:**
- Avoid in severe hepatic impairment (Child-Pugh C)
- Use caution with moderate impairment
## Contraindications
- Active pathological bleeding
- Severe hypersensitivity to apixaban
- Severe hepatic impairment (Child-Pugh C)
- Lesions/surgeries at high bleeding risk
## Adverse Effects
- **Bleeding** (major, minor, GI, intracranial)
- Anemia, epistaxis, contusion
- Less common: hepatotoxicity, allergic reactions
## Key Drug Interactions
- **Anticoagulants/Antiplatelets:** Increased bleeding risk
- **CYP3A4/P-gp inhibitors** (e.g., ketoconazole, ritonavir): May increase apixaban levels; reduce dose to 2.5 mg BID in AFib patients already on reduced dose criteria, otherwise avoid combination
- **CYP3A4/P-gp inducers** (e.g., rifampin, phenytoin): Reduce efficacy; avoid combination
- **NSAIDs:** Increased bleeding risk
## Monitoring
- No routine coagulation monitoring required; anti-factor Xa assay can be used to assess exposure if needed (refer to local lab reference ranges)
- Monitor hemoglobin, renal function, signs of bleeding
- Assess adherence and review drug interactions periodically
## Clinical Pearls
- For elective surgery, discontinue apixaban ≥24–48 hours (low bleeding risk) or ≥48–96 hours (high bleeding risk) pre-procedure; dependent on CrCl
- Andexanet alfa is the reversal agent for life-threatening bleeding
- Do not crush the tablet (binds to intestinal mucosa); if unable to swallow, tablet can be crushed and suspended in water or apple juice
- Missed dose: If >6 hours late, skip and take next dose as scheduled; do not double
*Educational disclaimer: This information is for educational purposes and does not replace professional judgment. Always verify current prescribing information from the manufacturer's labeling and consult local protocols, especially for pediatric and dose-adjusted populations.*
