Friday, February 11, 2022

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

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


Pharmacotherapeutic: Factor Xa inhibitor
Clinical: Anticoagulant
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


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


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


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)

 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

• 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

• 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

• 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

• 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


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


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


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


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


• Grapefruit products: may increase level/adverse effects


• 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


• 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


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

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