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# Apixaban (Eliquis)
## Overview
Apixaban is a selective, reversible inhibitor of both free and clot-bound factor Xa. It inhibits platelet thrombus formation without requiring a cofactor (like antithrombin) for activity.
## Primary Indications
* Reduction of risk of stroke/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/PE following initial therapy.
* Prophylaxis of DVT (may lead to PE) 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 apply: Age ≥80 years, Body weight ≤60 kg, or Serum creatinine ≥1.5 mg/dL.
* **DVT/PE Treatment:** 10 mg PO BID for 7 days, followed by 5 mg PO BID.
* **Recurrent DVT/PE Prophylaxis:** 2.5 mg PO BID (following at least 6 months of treatment).
* **Post-op Orthopedic Prophylaxis:** 2.5 mg PO BID. Start 12–24 hours after surgery. Duration: 12 days (knee) or 35 days (hip).
## Pediatric Dosing
**Not FDA-approved for pediatric patients.** Use in children is generally off-label and varies by institutional protocol (often based on weight-banded dosing in clinical trials like DIVERSITY). Consult a pediatric hematology specialist or local institutional handbook for weight-based dosing.
## Dose Adjustments
* **Renal Impairment:** No dose adjustment required for mild to moderate impairment. Use with caution in severe renal impairment (CrCl 15–29 mL/min); data is limited. *Note: Apixaban is not recommended in patients with CrCl <15 mL/min or on dialysis.*
* **Hepatic Impairment:** Avoid in severe hepatic impairment (Child-Pugh C). Use caution in moderate impairment (Child-Pugh B).
## Contraindications
* Hypersensitivity to apixaban.
* Active pathological bleeding.
## Adverse Effects
* **Major:** Hemorrhage (intracranial, gastrointestinal, ocular, etc.).
* **Common:** Anemia, nausea, bruising, epistaxis.
## Key Drug Interactions
* **Strong Dual Inhibitors/Inducers of CYP3A4 and P-gp:** Concurrent use significantly alters apixaban levels.
* *Avoid* concomitant use with strong dual inhibitors (e.g., ketoconazole, itraconazole, ritonavir).
* *Avoid* concomitant use with strong dual inducers (e.g., rifampin, carbamazepine, phenytoin, St. John’s Wort).
## Monitoring
* **Routine:** No standardized coagulation monitoring (PT/INR or aPTT) is required or reliable.
* **Clinical:** Baseline and periodic CBC (Hgb/Hct), renal function (SCr/CrCl), and liver function tests. Assess for signs of occult bleeding (melena, hematuria, symptomatic anemia).
## Clinical Pearls
* **Missed Dose:** Take as soon as remembered on the same day; do not double the dose to make up for a missed dose.
* **Transitioning:** If switching from warfarin, discontinue warfarin and start apixaban when INR <2.0. If switching to warfarin, overlap until therapeutic INR is achieved.
* **Reversal:** Andexanet alfa is the specific reversal agent, though it is high-cost and used selectively. Prothrombin complex concentrate (PCC) is often used per local protocol in life-threatening bleeds.
* **Surgery:** Discontinue at least 48 hours before elective surgery with moderate-to-high bleeding risk, or 24 hours before low-risk procedures.
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**Disclaimer:** This information is for educational purposes only. Clinical dosing, guidelines, and safety protocols vary based on regional standards and individual patient factors. Always verify prescribing information against current package inserts or institutional clinical decision support tools before administration.
