Apixaban (Eliquis): Side effects, interactions and more

What is Apixaban used for?

Apixaban brand name is called Eliquis and is used to;

  1. Treat deep vein thrombosis (DVT). This is when you have a blood clot in the leg.
  2. Treat pulmonary embolism (PE). This is when you have a blood clot in the lungs.
  3. Prevent stroke and blood clots in adults aged 18 and over who have abnormal heartbeat commonly referred to as atrial fibrillation (AF) with one or more of the following risk factors:
  4. Prevent venous thromboembolic events (DVT) and (PE) in adults
apixaban
apixaban

Apixaban Dose in various conditions

What used forRecommended doseRecommended FrequencyMaximum daily doseRecommended duration
Prevention of stroke and systemic embolism in non-valvular atrial fibrillation (NVAF), 5mgtwice daily10mgLong term
Initial dose For the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) 10 mgtwice daily20 mgfirst 7 days
Maintenance dose For the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) 5 mgtwice daily10 mgMinimum of 3 months but may be longer depending on risk  
For the prevention of recurrent DVT and PE in adults (following completion of 6 months of treatment for DVT or PE)2.5mgtwice daily5mgBased on an assessment of benefit against the risk for bleeding.
For the prevention of venous thromboembolism (VTE) in people who have undergone hip or knee replacement surgery2.5mgTwice daily to be started 12–24 hours after surgery. 32 to 38 days. (hip) 10 to 14 days. (knee)

Dosage in Renal impairment

Your dose does not usually need to be amended if you have mild to moderate renal impairment.

You should not usually be prescribed Apixaban if your kidneys are not working very well with creatinine clearance (CrCl) of less than 15 mL/minute.

If you are an adult that has atrial fibrillation (AF) and taking Apixaban to prevent stroke and blood clot and you meet two of the following criteria, your dose will usually be reduced to 2.5mg twice daily

  1.  CrCl is 15–29 mL/min (or serum creatinine is 133 micromol/L or greater)
  2. aged 80 years or over 
  3. weighs 60 kg or less.

Important information

  • Even though you will not need to monitor your international normalized ratio (INR), like the case of warfarin, you will still need to do other monitoring and regular review.
  • Your doctor may do baseline clotting screen, renal and liver function tests, and a full blood count at the start of treatment.
  • You will usually be required to do a full blood count and blood tests once a year to check that your kidney and liver are working as it should. However, your doctor may ask you to it more often if you are ill or if you have renal problems. Your doctor may stop your apixaban or prescribe a lower dose if your renal function declines, Your doctor may stop your Apixaban if there is an unexpected fall in haemoglobin and haematocrit as this may indicate bleeding. Apixaban is contraindicated in people with liver disease associated with coagulopathy.
  • You will usually have a review every three months. This review is done to check that you are taking your Apixaban as you should and also to check with any side effect you may be experiencing.
  • Do not stop taking Apixaban abruptly.
  • It is important that you take your Apixaban regularly as prescribed. This is because its anticoagulant effect may be lost 12 to 24 hours after you miss a dose and increases your chances of getting a clot or stroke.
  • You may temporarily stop Apixaban treatment if you require surgery or dental procedure depending on the bleeding risk associated with the procedure. Your doctor will let you know if you need to temporarily withhold Apixaban treatment.
  • Seek medical attention immediately if you notice any signs or symptoms of bleeding.  
  • This is because bleeding is the most common adverse effect of Apixaban and other anticoagulants.

Side effects of Apixaban

Bleeding is the most common adverse effect of apixaban.

Other adverse effects are nausea, bruising, and anaemia.

Do not take over-the-counter medicines such as non-steroidal anti-inflammatory drugs (NSAIDs) like Ibuprofen and aspirin as there is increased risk of bleeding when these medications are taken together with apixaban.

Apixaban Reversal

Andexxa is the first and only specific reversal agent for apixaban.

Missed doses

  • If you miss a dose of Apixaban, you can take the dose up to six hours before your next dose is due. If it is less than six hours before your next dose, then omit the missed dose and take your next scheduled dose as normal.
  • If you have taken a double dose of Apixaban, then omit the next scheduled dose and resume treatment in 24 hours as normal.
  • If you are unsure whether you have taken a dose, do not take a dose but continue with your next scheduled dose that is after 12 hours.
  • Carry your Eliquis® Alert Card at all times. You can get it from www.eliquis.co.uk (pdf).

Suitability

Apixaban is not suitable for some people. Those people include those who

  • have a known allergy to apixaban.
  • are pregnant, trying to get pregnant or breastfeeding.
  • have liver disease
  • your kidneys are not working very well with creatinine clearance (CrCl) of less than 15 mL/minute.
  • Taking some medication which interacts with apixaban like St John’s wort, HIV such as protease inhibitors (e.g. ritonavir) etc. see interactions.
  • Other anticoagulants (medicines that affect blood clottings, such as warfarin, enoxaparin rivaroxaban, or dabigatran as there is increased risk of bleeding when these medications are taken together unless switching between anticoagulants.
  • have had a recent brain or spinal injury or surgery
  • Currently bleeding a lot, such as a wound or a stomach ulcer
  • have a history of blood clots diagnosed with the antiphospholipid syndrome as Apixaban DOACs like Apixaban could be associated with increased rates of recurrent blood clots.
  • Have prosthetic heart valve.

Apixaban Interactions

  • Some medications can interact with Apixaban. Let your doctor know if you are taking these medicines before starting Apixaban:
  • Other anticoagulants, such as warfarin, enoxaparin rivaroxaban, or dabigatran as there is increased risk of bleeding when these medications are taken together. The only time it is used together is when to or from warfarin. See switching between anticoagulants.
  • Some medications used to treat fungal infections, such as ketoconazole, Itraconazole, voriconazole, and posaconazole.
  • Some medications used to treat bacterial infections such as clarithromycin, erythromycin, or rifampicin
  • St John’s wort often taken for depression
  • Some medications used to treat HIV such as protease inhibitors (e.g. ritonavir)
  • Medicines that are used to treat abnormal heartbeats, such as amiodarone, diltiazem dronedarone, quinidine and verapamil.
  • Some medicines used to prevent organ rejection after a transplant, such as ciclosporin.
  • Some medications used to treat epilepsy, such as carbamazepine and phenytoin as this reduces the amount of Apixaban.
  • Some medications used in treating depression Selective serotonin reuptake inhibitors or SSRIs or Serotonin and norepinephrine reuptake inhibitors SNRIs as there is increased risk of bleeding when these medications are taken together with apixaban
  • Some pain medication like non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and aspirin as there is increased risk of bleeding when these medications are taken together with apixaban.
  • Some medicines used to stop prevent blood clots called such as aspirin, clopidogrel, ticlopidine and ticagrelor as there is increased risk of bleeding when these medications are taken together with apixaban except on specialist advice

Switching anticoagulants

Switching from warfarin to apixaban

To switch from warfarin to apixaban, your doctor will usually advise you when to stop taking warfarin a few days before you start apixaban.

You will then have your international normalised ratio (INR) checked. This is a blood test used to check how quickly your blood’s clotting. This helps your doctor decide when its best to start taking apixaban.

Switching from apixaban to warfarin

To switch from apixaban to warfarin, you may need to take both medicines together for a few days.

You will then have your international normalised ratio (INR) checked. This is a blood test used to check how quickly your blood’s clotting. This helps your doctor decide when its best to stop taking apixaban.

Switching from apixaban to edoxaban, dabigatran or rivaroxaban

  • To switch from apixaban to edoxaban, dabigatran or rivaroxaban, You will be asked to stop apixaban and start edoxaban, dabigatran or rivaroxaban when the next dose of apixaban is due.

Switching from dabigatran, edoxaban, rivaroxaban or to apixaban:

  • To switch from edoxaban, dabigatran or rivaroxaban to apixaban, You will be asked to stop edoxaban, dabigatran or rivaroxaban and start apixaban when the next dose of edoxaban, dabigatran or rivaroxaban is due.

About the author

Nwasom is a pharmacy graduate and a pharmacist currently practicing in the United Kingdom. I have  great experience communicating with patient and their family as gained through working as a pharmacist in both the hospital and community pharmacy sector. I love writing so it was a natural thing to try and pass medical and health information on through writing.