General

**REMS Drug**

Pronunciation:
a-pix-a-ban


Trade Name(s)

  • Eliquis

Pregnancy Category
Category B

Ther. Class.
anticoagulants

Pharm. Class.
factor xa inhibitors

Indications

  • Decreases risk of stroke/systemic embolism associated with nonvalvular atrial fibrillation.
  • Prevention of deep vein thrombosis that may lead to pulmonary embolism following knee or hip replacement surgery.
  • Treatment of and reduction in risk of recurrence of deep vein thrombosis (DVT) or pulmonary embolism (PE)

Action

Acts as a selective, reversible site inhibitor of factor Xa, inhibiting both free and bound factor. Does not affect platelet aggregation directly, but does inhibit thrombin-induced platelet aggregation. Decreases thrombin generation and thrombus development.

Therapeutic Effect(s):

Treatment and prevention of thromboembolic events.

Pharmacokinetics

Absorption: 50% absorbed following oral administration.

Distribution: Unknown.

Metabolism and Excretion: 25% metabolized (mostly by CYP3A4) and excreted in urine and feces. Biliary and direct intestinal excretion account for fecal elimination.

Half-life: 6 hr (12 hr after repeated dosing due to prolonged absorption).

TIME/ACTION PROFILE (effect on hemostasis)

ROUTEONSETPEAKDURATION
POunknown3–4 hr†24 hr

†Blood levels.

Contraindication/Precautions

Contraindicated in:

  • Previous severe hypersensitivity reactions
  • Active pathological bleeding
  • Severe hepatic impairment;
  • Not recommended for use in patients with prosthetic heart valves;
  • Concurrent use of strong dual inducers of CYP3A4 and P-gp;
  • PE with hemodynamic instability or requiring thrombolysis or pulmonary embolectomy
  • Lactation: Should not be used.

Use Cautiously in:

  • Neuroaxial spinal anesthesia or spinal puncture, especially if concurrent with an indwelling epidural catheter, drugs affecting hemostasis, history of traumatic/repeated spinal puncture or spinal deformity (↑ risk of spinal hematoma);
  • Discontinuation ↑ risk of thromboses;
  • Surgery;
  • Renal impairment (dose ↓ may be required;
  • Moderate hepatic impairment (↑ risk of bleeding);
  • Concurrent use of strong dual inhibitors of CYP3A4 and P-gp systems (dose ↓ required);
  • OB: Use during pregnancy only if potential benefit outweighs possible risks to mother and fetus;Pedi: Safety and effectiveness not established.

Adverse Reactions/Side Effects

Hemat: BLEEDING

Misc: HYPERSENSITIVITY REACTIONS INCLUDING ANAPHYLAXIS

* CAPITALS indicate life-threatening.
Italics indicate most frequent.

Interactions

Drug-Drug

  • ↑ risk of bleeding with other anticoagulants , fibrinolytics , heparins , NSAIDs , SNRIs , SSRIs , or thrombolytics .
  • Concurrent use of strong inhibitors of both the CYP3A4 and P-gP enzyme systems (including clarithromycin , itraconazole , ketoconazole , and ritonavir ) ↑ levels and bleeding risk; dosage of apixaban should be ↓ to 2.5 mg twice daily. If other reasons for ↓ dose exist, apixaban should be avoided.
  • Inducers of the CYP3A4 enzyme system and the P-gp system including carbamazepine , phenytoin , rifampin will ↓ levels and may ↑ risk of thromboses; avoid concomitant use.

Drug-Natural Products:

Concurrent use St. John's wort , a strong dual inducer of the CYP3A4 and P-gp enzyme systems can ↓ levels and ↑risk of thromboses and should be avoided.

Route/Dosage

Reduction in Risk of Stroke/Systemic Embolism in Nonvalvular Atrial Fibrillation

PO: (Adults) 5 mg twice daily; Any 2 of the following: age ≥80 yr, weight ≤60 kg, serum creatinine ≥1.5mg/dL– 2.5 mg twice daily; Concurrent use of strong inhibitors of both CYP3A4 and P-gp– 2.5 mg twice daily; if patient already taking 2.5 mg twice daily, avoid concomitant use.

Renal Impairment
PO: (Adults) HD– 5 mg twice daily; HD and either age ≥80 yr or weight ≤60 kg– 2.5 mg twice daily.

Prevention of Deep Vein Thrombosis Following Knee or Hip Replacement Surgery

PO: (Adults) 2.5 mg twice daily, initiated 12–24 hr post-operatively (when hemostasis is achieved) continued for 35 days after hip replacement or 12 days after knee replacement.

Treatment of DVT or PE

PO: (Adults) 10 mg twice daily for 7 days, then 5 mg twice daily.

Reduction is Risk of Recurrence of DVT or PE

PO: (Adults) 2.5 mg twice daily after ≥6 mo of treatment of DVT or PE.

Availability

Tablets: 2.5 mg, 5 mg

Assessment

  • Assess patient for symptoms of stroke, DVT, PE, or peripheral vascular disease periodically during therapy.

Potential Diagnoses

Implementation

  • When converting from warfarin, discontinue warfarin and start apixaban when INR is <2.0.
  • When converting from apixaban to warfarin, apixaban affects INR, so INR measurements may not be useful for determining appropriate dose of warfarin. If continuous anticoagulation is necessary, discontinue apixaban and begin both a parenteral anticoagulant and warfarin at time of next dose of apixaban, dicontinue parenteral anticoagulant when INR reaches acceptable range.
  • When switching between apixaban and anticoagulants other than warfarin, discontinue one being taken and begin the other at the next scheduled dose.
  • For surgery, discontinue apixaban at least 48 hrs before invasive or surgical procedures with a moderate or high risk of unacceptable or clinically significant bleeding or at least 24 hrs prior to procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled.
  • PO: Administer twice daily without regard to food.
    • For patients who cannot swallow tablet, 5 mg and 2.5 mg tablets can be crushed, suspended in 60 mL of D5W, and administered immediately through a nasogastric tube; do not administer crushed tablets by oral route.

Patient/Family Teaching

  • Instruct patient to take apixaban as directed. Take missed doses as soon as remembered on the same day and resume twice daily administration; do not double doses. Do not discontinue without consulting health care professional; may increase risk of having a stroke, DVT, or PE. If temporarily discontinued, restart as soon as possible. Store apixaban at room temperature. Advise patient to read Medication Guide before beginning therapy and with each Rx refill in case of changes.
  • Inform patient that they may bruise and bleed more easily or longer than usual. Advise patient to notify health care professional immediately if signs of bleeding (unusual bruising, pink or brown urine, red or black, tarry stools, coughing up blood, vomiting blood, pain or swelling in a joint, headache, dizziness, weakness, recurring nose bleeds, unusual bleeding from gums, heavier than normal menstrual bleeding, dyspepsia, abdominal pain, epigastric pain) occurs or if injury occurs, especially head injury.
  • Caution patient to notify health care professional if skin rash or signs of severe allergic reaction (chest pain or tightness, swelling of face or tongue, trouble breathing or wheezing, feeling dizzy or faint) occur.
  • Advise patient to notify health care professional of medication regimen prior to treatment or surgery.
  • Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications. Risk of bleeding is increased with aspirin, NSAIDs, warfarin, heparin, SSRIs or SNRIs.
  • Inform patient having had neuraxial anesthesia or spinal puncture to watch for signs and symptoms of spinal or epidural hematomas (numbness or weakness of legs, bowel or bladder dysfunction). Notify health care professional immediately if symptoms occur.
  • Advise female patient to notify health care professional if pregnancy is planned or suspected or if breast feeding.

Evaluation/Desired Outcomes

Reduction in the risk and treatment of stroke and systemic embolism.

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