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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 and has a rapid onset of action, typically reaching peak plasma concentrations in 3 to 4 hours.
## 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).
* Prophylaxis of DVT/PE following hip or knee replacement surgery.
## 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.
* **Secondary Prophylaxis (Extended Treatment):** 2.5 mg orally twice daily.
* **Post-op Orthopedic Prophylaxis (Hip):** 2.5 mg twice daily for 35 days.
* **Post-op Orthopedic Prophylaxis (Knee):** 2.5 mg twice daily for 12 days.
## Pediatric Dosing
There is no FDA-approved pediatric dosing for apixaban. Dosing in pediatric patients is frequently restricted to specialized tertiary centers and governed by institutional protocols citing clinical trials like EINSTEIN-Jr (though typically using rivaroxaban) or registry data. Off-label use requires expert hematology consultation and weight-based nomograms.
## Dose Adjustments
* **Renal Impairment:** Generally no adjustment required. However, in NVAF, use 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.
* **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 (intracranial, gastrointestinal).
* **Common:** Anemia, nausea, bruising, epistaxis, and hematuria.
## Key Drug Interactions
* **Strong Dual Inhibitors/Inducers of CYP3A4 and P-gp:** Concurrent use with drugs like ketoconazole, itraconazole, ritonavir, or rifampin significantly alters apixaban exposure. Avoid or reduce dose as per prescribing information.
* **Anticoagulants/Antiplatelets/NSAIDs:** Combined use increases bleeding risk; avoid unnecessary polypharmacy.
## Monitoring
* **Clinical:** Assess for signs of bleeding (Hgb/Hct drops, dark stools, hematuria).
* **Renal/Hepatic:** Monitor CrCl and LFTs periodically.
* **Laboratory:** There is no standardized, routinely available assay to measure apixaban effect. Routine PT/INR monitoring is ineffective; anti-Xa assays (calibrated for apixaban) may be used in specialized settings to assess drug presence.
## 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.
* **Transitioning:** When stopping apixaban for surgery, hold for 48 hours for standard risk or 72 hours for high bleeding risk/renal impairment.
* **Reversal:** Andexanet alfa is the specific reversal agent, though it is costly and strictly indicated for life-threatening or uncontrolled bleeding.
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**Educational Disclaimer:** This information is for educational purposes only. Drug information is subject to change. Always consult the most current FDA-approved labeling (Package Insert) and institutional clinical guidelines before prescribing or administering any medication.
