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Direct Oral Anticoagulant — Factor Xa Inhibitor Pregnancy: Avoid — no clinical data; cross placenta

Apixaban (Orthopaedic VTE Prophylaxis)

Brand names: Eliquis

Adult dose

Dose: 2.5 mg twice daily
Route: Oral
Frequency: Twice daily
Max: 2.5 mg twice daily
Start 12–24 hours after surgery. Total hip replacement (THR): 32–38 days. Total knee replacement (TKR): 10–14 days. No routine coagulation monitoring required. Take with or without food.

Paediatric dose

Route:
Not licensed for paediatric VTE prophylaxis post-arthroplasty — seek specialist opinion

Dose adjustments

Renal

Caution if eGFR <30 mL/min — not recommended for VTE prophylaxis below this threshold; check creatinine before prescribing

Hepatic

Avoid in severe hepatic impairment (Child-Pugh C) or hepatic disease with coagulopathy

Clinical pearls

  • ADVANCE-3 trial (NEJM 2010): apixaban 2.5 mg BD for 35 days superior to enoxaparin 40 mg daily in THR — 1.4% vs 3.9% VTE/all-cause mortality (RRR 64%)
  • ADVANCE-2 trial (Lancet 2010): apixaban superior to enoxaparin for TKR VTE prophylaxis with comparable bleeding rates
  • NICE NG89: apixaban is a first-line option for VTE prophylaxis in THR (35 days) and TKR (14 days) — recommended alongside LMWH
  • No routine anticoagulation monitoring needed — advantage in primary care and community discharge setting
  • Reversal: andexanet alfa (Ondexxya) is licensed for apixaban reversal in life-threatening bleeding — not universally available

Contraindications

  • Active significant bleeding
  • Hepatic disease with coagulopathy
  • eGFR <15 mL/min
  • Concurrent strong CYP3A4 and P-gp inhibitors

Side effects

  • Bleeding — wound haematoma, haemorrhage
  • Anaemia
  • Bruising
  • Nausea
  • Elevated LFTs

Interactions

  • Strong CYP3A4 and P-gp inhibitors (ketoconazole, ritonavir, clarithromycin) — increase apixaban levels; avoid
  • Strong CYP3A4 and P-gp inducers (rifampicin, carbamazepine, phenytoin, St John's Wort) — decrease apixaban levels; avoid
  • Other anticoagulants and antiplatelets — additive bleeding risk

Monitoring

  • Renal function before initiation
  • Signs of bleeding — wound site, haematuria
  • LFTs before initiation

Reference: BNFc; BNF 90; ADVANCE-3 Trial (NEJM 2010); ADVANCE-2 Trial (Lancet 2010); NICE NG89; SPC Eliquis. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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