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# Apixaban (Eliquis)
## Overview
Apixaban is an oral, direct Factor Xa inhibitor. It provides predictable pharmacokinetics with a rapid onset (1–3 hours) and a half-life of approximately 12 hours. It does not require routine coagulation monitoring.
## Primary Indications
* Reduction of risk of stroke and systemic embolism in non-valvular atrial fibrillation (NVAF).
* Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE).
* Reduction in the risk of recurrent DVT and PE.
* Prophylaxis of DVT following hip or knee replacement surgery.
## Adult Dosing
* **NVAF:** 5 mg PO BID. Reduce to 2.5 mg BID if at least two of the following are present: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL.
* **Treatment of DVT/PE:** 10 mg PO BID for 7 days, followed by 5 mg PO BID.
* **Extended DVT/PE Prevention:** 2.5 mg PO BID after at least 6 months of initial treatment.
* **Post-operative DVT Prophylaxis:** 2.5 mg PO BID. Initiate 12–24 hours post-operatively. Duration: 12 days (knee) or 35 days (hip).
## Pediatric Dosing
Safety and efficacy are not established for patients <18 years. Dosage varies significantly via institutional protocols (e.g., modified adult dosing based on weight/BSA). **Consult pediatric hematology/oncology specialist for off-label dosing.**
## Dose Adjustments
* **Renal Impairment:** No dose adjustment necessary for mild-to-moderate impairment. Avoid use if CrCl <15 mL/min or in patients on dialysis (though clinical practice sometimes permits use in ESRD, refer to institutional protocols).
* **Hepatic Impairment:** Avoid in severe hepatic impairment (Child-Pugh C). Use with caution in moderate impairment.
## Contraindications
* Active pathological bleeding.
* Severe hypersensitivity reactions.
* Mechanical prosthetic heart valves (increased risk of valve thrombosis).
## Adverse Effects
* **Major:** Hemorrhage (gastrointestinal, intracranial, genital).
* **Other:** Anemia, nausea, bruising, hypersensitivity reactions.
## Key Drug Interactions
* **Strong Dual Inhibitors/Inducers:** Avoid concomitant use with strong CYP3A4 and P-gp inhibitors (e.g., ketoconazole, ritonavir) or strong inducers (e.g., carbamazepine, phenytoin, rifampin).
* **Antiplatelets/NSAIDs/SSRIs/SNRIs:** Increased risk of bleeding when used in combination with other agents affecting hemostasis.
## Monitoring
* **Baseline:** CBC, renal function (SCr/CrCl), LFTs.
* **Routine:** Periodic renal function and CBC to monitor for occult blood loss.
* **Coagulation:** Routine monitoring is not required. Anti-Factor Xa assays are available but not standardized for clinical routine use.
## Clinical Pearls
* **Reversal:** Andexanet alfa is the specific reversal agent. In life-threatening emergencies where unavailable, PCC (4-factor) may be utilized per hospital protocol.
* **Missed Dose:** Take as soon as remembered on the same day; do not double the dose to compensate.
* **Surgery:** Discontinue at least 48 hours before elective surgery with moderate-to-high bleeding risk, or 24 hours for minor procedures, depending on renal function.
* **Crushability:** Tablets may be crushed and suspended in 5% dextrose, water, or apple juice for NG/OG tube administration.
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*Disclaimer: This information is for educational purposes and does not replace professional clinical judgment. Always verify current prescribing information, institutional guidelines, and drug interaction databases before administration.*
