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# Apixaban (Eliquis)
## Overview
Apixaban is a selective, reversible inhibitor of both free and clot-bound factor Xa. It is an oral anticoagulant used for the prevention and treatment of thromboembolic events with a rapid onset and predictable pharmacokinetics.
## 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).
* Prophylaxis of DVT (which may lead to PE) following hip or knee replacement surgery.
* Reduction in the risk of recurrent DVT and PE following initial treatment.
## Adult Dosing
* **NVAF:** 5 mg orally twice daily.
* **DVT/PE Treatment:** 10 mg orally twice daily for 7 days, followed by 5 mg orally twice daily.
* **DVT/PE Prophylaxis (post-treatment):** 2.5 mg orally twice daily.
* **Post-op Orthopedic Prophylaxis:** 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 patients.** Dosing is off-label and varies significantly by age and weight; it should only be initiated under the guidance of a pediatric hematologist utilizing institutional protocols or clinical trial guidelines (e.g., EINSTEIN-Jr derivatives).
## Dose Adjustments
* **NVAF Criteria (Dose reduction to 2.5 mg BID):** Use if patient meets 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 needed for mild/moderate impairment. Avoid use if CrCl < 15 mL/min or on dialysis (limited clinical data).
* **Hepatic Impairment:** Avoid in severe impairment (Child-Pugh C). Use with caution in moderate impairment (Child-Pugh B).
## Contraindications
* Active pathological bleeding.
* Severe hypersensitivity to apixaban.
* Prosthetic heart valves (contraindicated due to increased risk of valve thrombosis).
## Adverse Effects
* **Major:** Hemorrhage (GI, intracranial, ocular).
* **Common:** Anemia, nausea, bruising, epistaxis.
## Key Drug Interactions
* **CYP3A4/P-gp dual inhibitors:** (e.g., ketoconazole, clarithromycin, ritonavir) Increase apixaban exposure; reduce dose by 50% or avoid if already on the 2.5 mg dose.
* **CYP3A4/P-gp dual inducers:** (e.g., rifampin, carbamazepine, phenytoin, St. John’s Wort) Decrease apixaban efficacy; avoid use.
* **Antiplatelets/NSAIDs/SSRIs:** Increase bleeding risk; monitor closely.
## Monitoring
* **Renal Function:** Periodic assessment of CrCl, especially if clinical status changes.
* **Coagulation:** Routine monitoring of PT/INR or aPTT is **not** recommended; these tests are not sensitive to apixaban activity. Anti-Xa assays can be used if urgent assessment is required for life-threatening bleeding or emergency surgery.
* **Signs of Bleeding:** Monitor hematocrit/hemoglobin and clinical signs of occult bleeding (e.g., dark stools, confusion).
## 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.
* **Transitions:** Often used for patients who cannot maintain stable INR on warfarin or who prefer avoiding routine blood work.
* **Reversal:** Andexanet alfa is a targeted reversal agent for life-threatening bleeding, though availability may be limited by institutional protocol.
* **Surgery:** Generally hold 48 hours prior to elective surgery with moderate/high bleeding risk; hold 24 hours for low-risk procedures.
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*Disclaimer: This information is for educational purposes for healthcare professionals. Dosing and management protocols may vary by institution. Always verify current prescribing information, package inserts, and local clinical guidelines before administration.*
