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# Apixaban (Eliquis)
## Overview
Apixaban is a direct factor Xa inhibitor that selectively blocks the active site of factor Xa, preventing thrombin generation and thrombus development. It has high oral bioavailability and a predictable pharmacokinetic profile.
## Primary Indications
* Reduction of risk of stroke/systemic embolism in nonvalvular atrial fibrillation (NVAF).
* Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE).
* Reduction in the risk of recurrent DVT/PE following initial treatment.
* Prophylaxis of DVT (which may lead to PE) following hip or knee replacement surgery.
## Adult Dosing
* **NVAF:** 5 mg orally twice daily. Reduce to 2.5 mg twice daily if criteria for dose reduction are met (see Dose Adjustments).
* **DVT/PE Treatment:** 10 mg orally twice daily for 7 days, followed by 5 mg orally twice daily.
* **Secondary Prophylaxis (post 6 months treatment):** 2.5 mg orally twice daily.
* **Post-Operative DVT Prophylaxis:**
* **Hip replacement:** 2.5 mg twice daily for 35 days.
* **Knee replacement:** 2.5 mg twice daily for 12 days.
## Pediatric Dosing
**Not FDA-approved for pediatric use.** Dosing in pediatrics is weight/age-dependent and typically managed through specialized hematology protocols (e.g., Einstein Junior/RE-PAVE trials). Consult institutional pediatric dosing guidelines.
## Dose Adjustments
* **NVAF Dose Reduction:** Reduce to 2.5 mg twice daily if patient has at least **two** of the following: Age ≥80 years, Body Weight ≤60 kg, or Serum Creatinine ≥1.5 mg/dL.
* **Renal Impairment:** No dose adjustment required in mild-to-moderate CKD. Use with caution in severe renal impairment (CrCl <15 mL/min) or patients on dialysis; clinical data are limited; dosing per official labeling is not established.
* **Hepatic Impairment:** Avoid in severe hepatic impairment (Child-Pugh C). Use with caution in moderate impairment (Child-Pugh B).
## Contraindications
* Active pathological bleeding.
* Severe hypersensitivity to apixaban.
## Adverse Effects
* **Major:** Hemorrhage (GI, intracranial, surgical site).
* **Common:** Anemia, nausea, bruising, epistaxis.
## Key Drug Interactions
* **Strong Dual Inhibitors/Inducers:** Contraindicated with strong dual inhibitors of CYP3A4 and P-gp (e.g., ketoconazole, itraconazole, ritonavir) — reduce dose or avoid. Avoid strong dual inducers (e.g., rifampin, carbamazepine, phenytoin, St. John’s Wort) as they significantly decrease apixaban exposure.
* **Anticoagulants/Antiplatelets:** Increased risk of bleeding when combined with NSAIDs, SSRIs/SNRIs, or other anticoagulants.
## Monitoring
* **Baseline/Routine:** Baseline CBC (hemoglobin/hematocrit), serum creatinine, and LFTs.
* **Bleeding:** Periodic assessment for signs of occult or overt bleeding.
* **Renal Function:** Monitor periodically, especially in elderly or those with labile renal function.
* **Lab testing:** Routine coagulation monitoring (PT/INR or aPTT) is not standard; Anti-Xa assays can be used if emergency assessment is necessary, but there is no widely standardized "therapeutic range."
## Clinical Pearls
* **Missed Doses:** If a dose is missed, take immediately on the same day. Do not double the dose to make up for a missed one.
* **Emergency Reversal:** Andexanet alfa is the designated FDA-approved reversal agent for life-threatening or uncontrolled bleeding.
* **Transitioning:** When switching from warfarin, stop warfarin and start apixaban when INR <2.0.
* **Crushability:** Tablets can be crushed and suspended in water, D5W, or apple juice for NG tube administration.
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*Disclaimer: This information is for educational purposes only. Prescribing information must be verified against current manufacturer labeling, institutional protocols, and clinical decision support systems (e.g., Lexicomp/UpToDate) before patient administration.*
