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# Apixaban (Eliquis)
## Overview
Apixaban is an oral, direct, selective, and reversible factor Xa inhibitor anticoagulant.
## Primary Indications
* **Stroke and systemic embolism prophylaxis** in patients with nonvalvular atrial fibrillation (NVAF).
* **Treatment of deep vein thrombosis (DVT)**.
* **Treatment of pulmonary embolism (PE)**.
* **Prevention of recurrent DVT and PE**.
## Adult Dosing
* **NVAF:** 5 mg orally twice daily.
* Dose reduction to 2.5 mg orally twice daily is recommended for patients with at least two of the following criteria: age ≥ 80 years, body weight ≤ 60 kg, or serum creatinine ≥ 1.5 mg/dL.
* **Treatment of DVT and PE; Prevention of recurrent DVT and PE:**
* Initial treatment: 10 mg orally twice daily for 7 days, followed by 5 mg orally twice daily.
## Pediatric Dosing
Established pediatric dosing is not available. Use is generally not recommended outside of clinical trials.
## Dose Adjustments
* **Renal Impairment:** No dose adjustment is recommended in patients with mild to moderate renal impairment. For severe renal impairment (CrCl < 25 mL/min), use with caution and consider dose reduction (2.5 mg BID) if they meet criteria for NVAF dose reduction. Avoid use in patients on dialysis.
* **Hepatic Impairment:** No dose adjustment is needed in patients with mild to moderate hepatic impairment (Child-Pugh A or B). Avoid use in severe hepatic impairment.
* **Concomitant P-glycoprotein (P-gp) Inhibitors/Inducers:** Monitor for signs of bleeding or reduced efficacy. Strong P-gp inhibitors (e.g., ketoconazole) may increase apixaban exposure; consider dose adjustment to 2.5 mg BID if patient meets NVAF dose reduction criteria. Strong P-gp inducers (e.g., rifampin) may decrease apixaban exposure; consider alternative therapy.
## Contraindications
* Active major bleeding.
* History of hypersensitivity to apixaban.
## Adverse Effects
* **Bleeding:** The most common and serious adverse effect; can occur at any site and may be life-threatening.
* **Bruising, hematoma.**
* **Nausea.**
## Key Drug Interactions
* **Strong CYP3A4 and P-gp Inhibitors:** Increased risk of bleeding (e.g., azole antifungals, protease inhibitors).
* **Strong CYP3A4 and P-gp Inducers:** Decreased efficacy (e.g., rifampin, carbamazepine, phenytoin).
* **Antiplatelet Agents and other Anticoagulants:** Increased risk of bleeding. Consider risks vs benefits for combined use.
* **NSAIDs:** Increased risk of gastrointestinal bleeding.
## Monitoring
* Regular clinical assessment for signs and symptoms of bleeding or thrombosis.
* No routine laboratory monitoring of anticoagulant activity is required.
* Monitor renal function periodically.
## Clinical Pearls
* Apixaban does not require routine coagulation monitoring.
* Bridging anticoagulation with heparin or LMWH is generally not necessary when initiating or discontinuing apixaban, unless clinically indicated for a specific reason (e.g., impending surgery).
* If mechanical prophylaxis for VTE prevention post-orthopedic surgery is stopped, consider initiating apixaban.
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**Disclaimer:** This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and institutional protocols to ensure appropriate and safe patient care.
