Apixaban: Uses, Indications, Dosages, Precautions, Contraindications, Side Effects & Interactions

Apixaban

(a-pix-a-ban)
Classification 
Pharmacotherapeutic: Factor Xa inhibitor
Clinical: Anticoagulant

Eliquis

CATEGORY AND SCHEDULE

Pregnancy Risk Category: B

Do not confuse:

apixaban with rivaroxaban, argatroban, or dabigatran

General Information

Apixaban belongs to the factor Xa inhibitor group of anticoagulant group of drugs. They are effective for reducing the risk of stroke, systemic embolism in pts with nonvalvular atrial fibrillation. Prophylaxis of DVT following hip or knee replacement surgery, and also to treat  DVT and PE and to reduce the risk of recurrent DVT/PE following initial therapy

Apixaban can cause severe reactions, such as: Increased risk for bleeding/hemorrhagic events. May cause serious, potentially fatal bleeding, accompanied by one or more of the following: a decrease in Hgb of 2 g/dL or more; a need for 2 or more units of packed RBCs; bleeding occurring at one of the following sites: intracranial, intraspinal, intraocular, pericardial, intra-articular, intramuscular with compartment syndrome, retroperitoneal. Serious reactions include jaundice, cholestasis, cytolytic hepatitis, Stevens-Johnson syndrome, hypersensitivity reaction, anaphylaxis

Action

Selectively blocks active site of factor Xa, a key factor in the intrinsic and extrinsic pathway of blood coagulation cascade

Therapeutic Effect

Inhibits clot-induced platelet aggregation, fibrin clot forma

Availability (Rx)

Tablets: 2.5 mg, 5 mg

Uses

Deep venous thrombosis(DVT) after hip or knee replacement, to prevent stroke and embolism in atrial fibrillation (nonvalvular)

Unlabeled uses: Prevention of recurrent stroke or TIA

Precautions

Pregnancy (B), Breastfeeding, dialysis, hepatic/renal disease, labor, surgery, prosthetic heart valves

Black Box Warning: Abrupt discontinuation, epidural, spinal anesthesia, lumbar puncture

Make sure to tell your doctor if:

• You have heart problems

• You have hepatic diseases

• You have kidney problems

• You are taking other medicines

Indications and Dosages

‣ To Treat deep vein thrombosis (DVT) and pulmonary embolism (PE)

PO

• Adults: 10 mg bid × 7 days, then 5 mg bid ≥6 mo, to reduce recurrence >6  mo 2.5 mg bid

‣ To reduce risk of recurrence of deep vein thrombosis and pulmonary embolism after completion of treatment for acute DVT or PE

PO

• Adults: 2.5 mg bid daily after at least  6 mo of treatment for DVT or PE

‣ To Treat DVT prophylaxis and PE prophylaxis in patients undergoing knee or hip replacement surgery

PO

• Adults: 2.5 mg twice daily beginning 12 to 24 hours after surgery and lasting 12 days for knee replacement and 35 days for hip replacement

‣ To Treat Stroke prophylaxis and systemic embolism prophylaxis

PO

• Adults: 5 mg bid; in those with any 2 of the following—age ≥80 yr, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL—reduce the dose to 2.5 mg bid. Also decrease the dose to 2.5 mg bid (strong inhibitor of both CYP3A4 and Pglycoprotein)

‣ Dosage in Renal Impairment

PO

• DVT/PE/Reduce Risk Recurrent DVT, Postoperative: No adjustment

• Nonvalvular A-fib, HD:SCr < 1.5: No adjustment

• SCr 1.5 or greater, age older than 80 yrs, weight 60 kg or less: 2.5 mg 2 times/day

• Hemodialysis end-stage renal disease maintained on hemodialysis, adult: 5 mg bid; reduce to 2.5 mg bid if patient is ≥80 yr or ≤60 kg

‣ Dosage in Hepatic Impairment

• Mild Impairment: No dose adjustment

• Moderate Impairment: Use caution

• Severe Impairment: Not recommended

Pharmacokinetics

Readily absorbed after PO administration. Peak plasma concentration: 3–4 hrs.

Protein binding: 87%. Metabolized in liver. Excreted primarily in urine, feces.

Half-life: 12 hrs

Implementation

PO route

• Give without regard to meals

• If elective surgery or invasive procedures with moderate or high risk for bleeding, discontinue apixaban at least 24–48 hrs prior to procedure

Contraindications

Severe hypersensitivity to apixaban. Active pathologic bleeding

Cautions: Mild to moderate hepatic impairment, severe renal impairment (may increase bleeding risk). Avoid use in pts with severe hepatic impairment, prosthetic heart valve, significant rheumatic heart disease

Interactions

Individual drugs

• Antiplatelets, aspirin, fibrinolytics, heparin NSAIDs (chronic use): Possibly increased risk of bleeding 

• Strong dual inducers of CYP3A4 and P-gp such as carbamazepine, phenytoin, rifampin: Decreased effectiveness of apixaban strong dual inhibitors of CYP3A4 and P-gp such as clarithromycin, itraconazole

Drug/laboratory tests

• PT, PTT, INR, coagulation studies

Drugs/food

• Grapefruit products: may increase level/adverse effects

Herbal

• St. John’s wort may decrease level/effect

• Flaxseed, garlic, ginger, ginkgo biloba, ginseng, omega-3 may increase risk of bleeding

Side effects

• CNS: Hemorrhagic stroke, syncope 

• CV: Hypotension 

• EENT: Epitaxis, gingival bleeding, ocular hemorrhage 

• GI: Elevated bilirubin and liver enzymes, GI bleeding or hemorrhage, fresh bleeding from rectum, hematemesis, melena, rectal hemorrhage 

• GU: Hematuria, vaginal hemorrhage 

• HEME: Excessive bleeding, including hemorrhage, hemorrhagic anemia, thrombocytopenia 

• SKIN: Ecchymosis, petechiae, rash 

• MS: Muscle hemorrhage 

• RESP: Hemoptysis 

• Other: Anaphylaxis, angioedema, elevated alkaline phosphatase, hematomas at injection sites

 

Nursing considerations

Baseline assessment

• Obtain baseline CBC

• Question history of bleeding disorders, recent surgery, spinal punctures, intracranial hemorrhage, bleeding ulcers, open wounds, anemia, hepatic impairment

• Obtain full medication history including herbal products

Intervention/evaluation

• Periodically monitor CBC, stool for occult blood

• Be alert for complaints of abdominal/back pain, headache, confusion, weakness, vision change (may indicate hemorrhage)

• Question for increased menstrual bleeding/discharge

• Assess for any sign of bleeding: bleeding at surgical site, hematuria, blood in

stool, bleeding from gums, petechiae, ecchymosis

Equipment must be available for anaphylaxis

• Bleeding: bleeding may occur from any body system; may be fatal if severe

• Neurologic status: monitor for impairment, including numbness, paresthesia, weakness, confusion, back pain, bowel/bladder impairment; notify prescriber immediately 

• Abrupt discontinuation: do not discontinue abruptly; if bleeding occurs, consider using another anticoagulant to prevent thromboembolic events 

• Epidural, spinal anesthesia, lumbar puncture: avoid use in these conditions, risk of hematoma and permanent paralysis, may be increased with use of other anticoagulants, thrombolytics, antiplatelets 

• Hypersensitivity: rash, itching, chills, fever; report to prescriber 

• Beers: avoid in older adults; may cause increased risk of bleeding, decreased creatinine clearance

Evaluation

Positive therapeutic result

• Prevention/treatment of DVT

• Adequate anticoagulati

Patient/family teaching

• Instruct patient to Do not take/discontinue any medication except on advice from physician

• Tell patient unable to swallow whole tablets to crush tablet and mix with apple juice or water or mix with applesauce and take immediately

• Tell patient not to stop taking apixaban without first consulting prescriber. If patient misses a dose, instruct him to take it as soon as possible on the same day and resume the dosing schedule the next day. Caution patient not to double dose to make up for the missed dose the day before.

• Report blood-tinged mucus from coughing, heavy menstrual bleeding,

headache, vision problems, weakness, abdominal pain, frequent bruising, bloody

urine or stool, joint pain or swelling

• Advise patient to report any unusual bleeding or bruising to the prescriber

• Inform patient that it may take longer for her to stop bleeding and to take bleeding precautions, such as avoiding the use of a razor and using a soft-bristle toothbrush

• Tell patient to alert all prescribers to use of apixaban therapy before any invasive procedure, including dental work, is scheduled. Advise female patient to notify prescriber immediately if pregnancy is suspected or known

• Avoid alcohol, aspirin, NSAIDs, herbal supplements, grapefruit products