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# Apixaban (Eliquis)
## Overview
Apixaban is an oral, direct factor Xa inhibitor, a type of anticoagulant used to prevent blood clots.
## Primary Indications
* **Stroke and systemic embolism prophylaxis in non-valvular atrial fibrillation (NVAF)**
* **Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE)**
* **Prevention of recurrent DVT and PE**
* **Prophylaxis 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 to 2.5 mg twice daily** if **two** of the following criteria are met: age ≥ 80 years, body weight ≤ 60 kg, or serum creatinine ≥ 1.5 mg/dL.
* **Treatment of DVT/PE and prevention of recurrent DVT/PE:** 10 mg orally twice daily for 7 days, followed by 5 mg orally twice daily.
* **DVT Prophylaxis after hip/knee replacement:** 2.5 mg orally twice daily. Initial dose is typically 12-24 hours after surgery.
## Pediatric Dosing
Established pediatric dosing for apixaban is **not available**. Its use in pediatric populations is generally limited to investigational settings or specific clinical situations under specialist guidance.
## Dose Adjustments
* **Renal Impairment:** Dose reduction to 2.5 mg twice daily in NVAF patients taking apixaban for stroke prophylaxis if **two** of the following criteria are met: age ≥ 80 years, body weight ≤ 60 kg, or serum creatinine ≥ 1.5 mg/dL. No dose adjustment is needed for moderate or severe renal impairment in patients treated for DVT/PE or for DVT prophylaxis after hip/knee replacement, unless the NVAF dose reduction criteria are met.
* **Hepatic Impairment:** Generally avoided in patients with severe hepatic impairment or active liver disease with coagulopathy. Dose adjustment is not typically required for mild to moderate hepatic impairment (Child-Pugh A or B).
* **Concomitant P-glycoprotein (P-gp) and strong CYP3A4 inhibitors/inducers:** Consider dose reduction in NVAF patients if taking a strong P-gp inhibitor (e.g., verapamil, amiodarone, diltiazem). Avoid concomitant use with strong P-gp and strong CYP3A4 inducers (e.g., rifampin).
## Contraindications
* Active bleeding
* Known history of drug-induced immune thrombocytopenia with apixaban
## Adverse Effects
* **Most common:** Bleeding (may be serious or fatal). Symptoms include unusual bruising, prolonged bleeding from cuts, nosebleeds, bleeding gums, blood in urine or stool, heavy or prolonged menstrual bleeding.
* Less common: Nausea, anemia.
## Key Drug Interactions
* **Strong CYP3A4 and P-glycoprotein (P-gp) inducers:** (e.g., rifampin) can significantly decrease apixaban exposure and efficacy. Avoid concomitant use.
* **Strong CYP3A4 and P-gp inhibitors:** (e.g., ketoconazole, itraconazole, ritonavir) can increase apixaban exposure.
* **Other anticoagulants, antiplatelets, and NSAIDs:** Increased risk of bleeding.
## Monitoring
* Routine monitoring of coagulation parameters (e.g., INR, aPTT) is **not required** for apixaban.
* Monitor for signs and symptoms of bleeding or thrombosis.
* Assess renal function periodically, especially in patients at risk of renal decline.
## Clinical Pearls
* Apixaban does not require dietary modifications or routine coagulation monitoring.
* In patients requiring urgent surgery or thrombolysis, reversal agents for other anticoagulants may be considered, though specific reversal agents for apixaban are not currently widely available or standard of care. Consult a hematologist or toxicologist.
* Missed dose: If a dose is missed, take it immediately. If it is almost time for the next dose, skip the missed dose and continue with the regular schedule. Do not take two doses at the same time.
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***Disclaimer:** This information is intended for clinical support and does not replace professional medical advice, diagnosis, or treatment. Always verify current prescribing information with the official product monograph or a trusted drug reference database before making clinical decisions. Dosing and management may vary based on individual patient factors and local institutional protocols.*
