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Direct Oral Anticoagulant (DOAC) — Factor Xa Inhibitor Pregnancy: Contraindicated

Apixaban

Brand names: Eliquis

Adult dose

Dose: AF: 5 mg BD; DVT/PE treatment: 10 mg BD for 7 days then 5 mg BD; DVT/PE prophylaxis: 2.5 mg BD
Route: Oral
Frequency: Twice daily
Max: 10 mg twice daily (acute treatment phase)
AF dose reduction to 2.5 mg BD if ≥2 of: age ≥80, weight ≤60 kg, creatinine ≥133 µmol/L. No routine INR monitoring needed.

Paediatric dose

Route:
Seek specialist opinion — not licensed in children under 18

Dose adjustments

Renal

Avoid if CrCl <25 mL/min for AF. Caution in renal impairment — apixaban partially renally cleared.

Hepatic

Avoid in severe hepatic impairment or hepatic disease associated with coagulopathy.

Clinical pearls

  • Antidote: Andexanet alfa (AndrexXa) — approved for life-threatening bleeding; expensive and not universally available. PCC (Beriplex) used off-label as alternative.
  • ARISTOTLE trial: apixaban superior to warfarin in AF — lower stroke, bleeding, and mortality
  • No bridging required for most procedures — use periprocedural guidance based on bleeding risk
  • MHRA: DOACs not suitable for mechanical heart valves (ROCKET trial showed harm with rivaroxaban)

Contraindications

  • Active significant bleeding
  • Severe hepatic impairment
  • Mechanical heart valves or haemodynamically significant rheumatic mitral stenosis (warfarin preferred)
  • Pregnancy

Side effects

  • Bleeding (major risk)
  • Anaemia
  • Bruising
  • Nausea
  • Elevated LFTs

Interactions

  • Strong CYP3A4/P-gp inhibitors: itraconazole, ketoconazole, ritonavir (increase apixaban levels — avoid)
  • Strong CYP3A4/P-gp inducers: rifampicin, carbamazepine, phenytoin (reduce apixaban levels — avoid)
  • Other anticoagulants and antiplatelet agents (increased bleeding)

Monitoring

  • Renal function annually (more frequently if eGFR <60)
  • LFTs at baseline
  • Signs of bleeding

Reference: BNFc; BNF 90; NICE NG196 (Atrial Fibrillation); ARISTOTLE Trial (NEJM 2011); MHRA DOAC Safety Update. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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