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# Apixaban (Eliquis)
## Overview
Apixaban is an oral, direct, and selective Factor Xa inhibitor, acting as an anticoagulant.
## Primary Indications
* **Nonvalvular Atrial Fibrillation (NVAF):** To reduce the risk of stroke and systemic embolism.
* **Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE):** For the treatment of DVT and PE, and to reduce the risk of recurrent DVT and PE.
* **Prophylaxis of DVT:** To reduce the risk of DVT, which may lead to PE, in patients who have undergone hip or knee replacement surgery.
## Adult Dosing
* **NVAF:** 5 mg orally twice daily.
* *Dose Reduction:* 2.5 mg orally twice daily if **two or more** of the following criteria are met: age ≥ 80 years, body weight ≤ 60 kg, and serum creatinine ≥ 1.5 mg/dL.
* **Treatment of DVT and PE:** 10 mg orally twice daily for the first 7 days, followed by 5 mg orally twice daily.
* **Reduction of Recurrent DVT and PE:** 2.5 mg orally twice daily.
* **DVT Prophylaxis Post-Hip/Knee Replacement:** 2.5 mg orally twice daily, with the first dose taken postoperative. Duration: 10-14 days for hip replacement, 10-14 days for knee replacement. Duration may be extended up to 35 days for hip replacement.
## Pediatric Dosing
Established pediatric dosing is not standard. Consult specialized pediatric guidelines for use in this population.
## Dose Adjustments
* **Renal Impairment:** No dose adjustment needed in mild or moderate impairment. For severe impairment (CrCl < 15 mL/min or end-stage renal disease on dialysis), data is limited, and caution is advised. For NVAF, if criteria for dose reduction (age ≥ 80, weight ≤ 60 kg, SCr ≥ 1.5 mg/dL) are met, reduce dose to 2.5 mg BID regardless of renal function.
* **Hepatic Impairment:** Generally not recommended in severe hepatic impairment or any hepatic disease that has associated hemostatic defects. Use with caution in mild to moderate impairment.
* **Concomitant Strong P-glycoprotein (P-gp) and Strong CYP3A4 Inhibitors:** Dose reduction to 2.5 mg twice daily for NVAF if indicated.
* **Concomitant Strong P-gp and Strong CYP3A4 Inducers:** No dose adjustment.
## Contraindications
* Active clinically significant bleeding.
* History of hypersensitivity to apixaban.
## Adverse Effects
* **Bleeding:** The most significant risk. Can occur anywhere and may be serious or life-threatening. Signs include hematuria, epistaxis, bruising, prolonged bleeding from cuts, menorrhagia, GI bleeding (melena, hematochezia), hemoptysis, and neurological bleeding.
* Anemia
* Nausea
* Hypotension
## Key Drug Interactions
* **CYP3A4 and P-gp Inhibitors (e.g., ketoconazole, itraconazole, ritonavir, clarithromycin):** May increase apixaban concentrations and bleeding risk. Consider dose reduction.
* **CYP3A4 and P-gp Inducers (e.g., rifampin, carbamazepine, phenytoin):** May decrease apixaban concentrations. No specific dose adjustment recommended, but monitor for efficacy.
* **Other Anticoagulants and Antiplatelets (e.g., warfarin, heparin, aspirin, clopidogrel):** Increased risk of bleeding. Avoid concurrent use unless necessary, and monitor closely.
* **NSAIDs:** Increased risk of GI bleeding.
## Monitoring
* **Clinical Monitoring:** Regular assessment for bleeding signs and symptoms is crucial. Monitor for signs of gastrointestinal bleeding (dark, tarry stools, coffee-ground emesis) and neurological signs of bleeding (headache, focal deficits).
* **Laboratory Monitoring:** Routine coagulation tests (PT/INR, aPTT) are **not** useful for monitoring apixaban's anticoagulant effect. Anti-Factor Xa levels can be used if there is a need to further evaluate significant bleeding or before urgent procedures, but turnaround time is a limitation.
## Clinical Pearls
* Apixaban has a predictable pharmacokinetic and pharmacodynamic profile, generally requiring no routine monitoring.
* Bridging with heparin or LMWH is generally **not** required when discontinuing apixaban for elective surgery.
* If an emergency procedure is required and time is limited, anti-Factor Xa levels can be assessed, though reversibility agents are not standardly available.
* Apixaban is a P-gp substrate. Avoid coadministration with strong P-gp inhibitors where possible, or consider dose reduction if indicated.
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**Disclaimer:** This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines for complete details, contraindications, and updated recommendations before initiating or modifying therapy.
