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# Apixaban (Eliquis)
## Overview
Apixaban is a direct oral anticoagulant that inhibits Factor Xa, a key enzyme in the coagulation cascade. It is a selective inhibitor with no direct effect on platelets.
## Primary Indications
* Non-valvular atrial fibrillation (NVAF) to reduce the risk of stroke and systemic embolism.
* Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE).
* Prophylaxis of DVT and 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, 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 (post-orthopedic surgery):** 2.5 mg orally twice daily, starting 12-24 hours after surgery. Duration: 10-35 days depending on surgery type.
## Pediatric Dosing
Use in pediatric patients is not established.
## Dose Adjustments
* **Renal Impairment:** Dose reduction to 2.5 mg twice daily in NVAF is indicated if serum creatinine is ≥ 1.5 mg/dL **AND** age is ≥ 80 years **OR** body weight is ≤ 60 kg. No dose adjustment is recommended for mild to moderate renal impairment (CrCl > 15 mL/min) for other indications, but caution is advised. Use in severe renal impairment (CrCl < 15 mL/min), including patients on dialysis, is not recommended.
* **Hepatic Impairment:** Use is not recommended in patients with severe hepatic impairment, or in those with hepatic disease or coagulopathy related to hepatic disease. Use with caution in mild to moderate hepatic impairment. Drug concentrations may be increased in patients with marked elevation of baseline total bilirubin (>3 upper limit of normal [ULN]), AST (>2 ULN), or known cirrhosis.
## Contraindications
* Active major bleeding.
* Known history of hypersensitivity to apixaban or any component of the formulation.
## Adverse Effects
* **Major Bleeding:** This is the most significant risk. Symptoms may include (but are not limited to) coughing or vomiting blood, blood in urine or black/tarry stools, and unexpected severe or prolonged pain.
* **Other:** Bruising, epistaxis, hematuria, gastrointestinal hemorrhage.
## Key Drug Interactions
* **Strong CYP3A4 and P-glycoprotein (P-gp) inhibitors:** Increase apixaban exposure. Examples include ketoconazole, itraconazole, ritonavir, and clarithromycin. Consider alternative anticoagulants or dosing adjustments if coadministered.
* **Strong CYP3A4 and P-gp inducers:** Decrease apixaban exposure. Examples include rifampin, carbamazepine, and phenytoin. Consider alternative anticoagulants or monitoring for reduced efficacy.
* **Antiplatelet agents, other anticoagulants, NSAIDs:** Increase bleeding risk. Consider risk vs. benefit if coadministration is necessary.
## Monitoring
* Monitoring of apixaban plasma levels is not routinely required.
* Monitor for signs and symptoms of bleeding and anemia.
## Clinical Pearls
* Apixaban has a relatively short half-life compared to warfarin, meaning it needs to be taken consistently twice daily as prescribed.
* There is no routine antidote for apixaban; however, Andexanet alfa is an FDA-approved reversal agent for apixaban in life-threatening or uncontrollable bleeding. Its use should be guided by a specialist.
* If an anticoagulant procedure is required and interruption of apixaban is necessary, timing of drug cessation and reinitiation should be individualized based on patient risk factors and the procedure. Local protocols may provide guidance.
* When switching from apixaban to warfarin or another anticoagulant, ensure appropriate overlap and transition strategies are followed according to guidelines to maintain adequate anticoagulation and minimize risks.
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*Disclaimer: This information is for educational purposes and does not substitute for professional medical judgment. Always consult the most current prescribing information and relevant guidelines for complete and up-to-date information.*
