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# Apixaban (Eliquis)
## Overview
Apixaban is a highly selective, reversible, direct inhibitor of free and clot-bound Factor Xa. It inhibits both prothrombinase activity and platelet thrombus formation. It has high oral bioavailability and is primarily metabolized by CYP3A4, with renal excretion of unchanged drug accounting for approximately 27% of clearance.
## Primary Indications
* Reduction of risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF).
* Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE).
* Reduction in the risk of recurrent DVT and PE following initial therapy.
* 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 the patient meets at least two of the following: Age ≥80 years, Body weight ≤60 kg, or Serum creatinine ≥1.5 mg/dL.
* **DVT/PE Treatment:** 10 mg orally twice daily for 7 days, followed by 5 mg orally twice daily.
* **DVT/PE Prophylaxis (Recurrence):** 2.5 mg orally twice daily after at least 6 months of initial treatment.
* **Post-Operative Prophylaxis (Hip/Knee):** 2.5 mg orally twice daily. Start 12–24 hours post-surgery. Duration: 12 days (knee) or 35 days (hip).
## Pediatric Dosing
**Not FDA-approved for pediatric use.** Dosing is determined by institutional protocols or clinical trials (e.g., EINSTEIN-Jr). Off-label use must be guided by specialized pediatric hematology guidelines, typically weight-based.
## Dose Adjustments
* **Renal Impairment:** No dose adjustment required for mild/moderate impairment. Avoid use if CrCl <15 mL/min or in patients on dialysis (limited clinical data).
* **Hepatic Impairment:** Avoid in severe hepatic impairment (Child-Pugh C). Use with caution in moderate impairment (Child-Pugh B).
* **CYP3A4/P-gp Interactions:** If used concomitantly with strong dual inhibitors (e.g., ketoconazole, ritonavir), reduce dose by 50% (or avoid if already on 2.5 mg). Avoid with strong dual inducers (e.g., rifampin, carbamazepine).
## Contraindications
* Active pathological bleeding.
* Severe hypersensitivity to apixaban.
## Adverse Effects
* **Major:** Hemorrhage (gastrointestinal, intracranial, epistaxis, hematuria).
* **Common:** Anemia, nausea, bruising, and hematoma.
## Key Drug Interactions
* **Antiplatelets/Anticoagulants:** Increased risk of life-threatening bleeding with NSAIDs, aspirin, clopidogrel, SSRIs/SNRIs, and other anticoagulants.
* **CYP3A4/P-gp Modulators:** Strong inhibitors increase apixaban plasma concentrations; strong inducers decrease concentration and therapeutic efficacy.
## Monitoring
* **Renal:** Periodic assessment of serum creatinine/CrCl.
* **Clinical:** Hemoglobin/hematocrit (if bleeding suspected), signs of overt or occult bleeding (e.g., melena, hematuria).
* **Coagulation:** Routine monitoring is not required or recommended; standard PT/INR tests are unreliable for measuring apixaban effect.
## Clinical Pearls
* **Missed Dose:** Take as soon as remembered on the same day; do not double the dose to make up for a missed one.
* **Surgery:** Discontinue at least 48 hours before elective surgery with moderate/high bleeding risk, or 24 hours for minor procedures.
* **Reversal:** Andexanet alfa is the specific reversal agent for life-threatening or uncontrolled bleeding.
* **Crushability:** Tablets can be crushed and suspended in water, D5W, or apple juice, and administered via NG/OG tube if necessary.
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*Disclaimer: This information is for educational purposes and does not constitute medical advice. Prescribing information, local protocols, and off-label usage should always be verified against the official FDA-approved labeling or institutional guidance before clinical administration.*
