Direct Oral Anticoagulant — Factor Xa Inhibitor Pregnancy: No data from use in pregnant women; as a precautionary measure it is preferable to avoid apixaban during pregnancy. Breast-feeding: excretion in human milk unknown, a risk to the suckling child cannot be excluded — decide whether to discontinue breast-feeding or apixaban. Animal studies showed no effect on fertility. (SPC §4.6)

Apixaban (Orthopaedic VTE Prophylaxis)

Brand names: Eliquis

This entry covers apixaban used for venous thromboembolism prophylaxis after major orthopaedic surgery such as elective hip and knee arthroplasty; it is an oral direct factor Xa inhibitor.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: 2.5 mg twice daily

Route: Oral

Frequency: Twice daily

Indication on this page matches SPC §4.2 'Prevention of VTE (VTEp): elective hip or knee replacement surgery'. TIMING: the initial dose should be taken 12 to 24 hours after surgery; physicians may consider the potential benefits of earlier anticoagulation for VTE prophylaxis as well as the risks of post-surgical bleeding in deciding on the time of administration within this time window. DURATION: hip replacement surgery 32 to 38 days; knee replacement surgery 10 to 14 days. MISSED DOSE: the patient should take apixaban immediately and then continue with twice daily intake as before. NO DOSE ADJUSTMENT required for elderly or body weight in VTEp. PRODUCT NOTE: the retrieved SPC is for 'Apixaban 1 mg/1 ml Oral suspension', so the SPC expresses the dose as 2.5 mg (2.5 ml); confirm the strength/volume for the tablet formulation actually used. OTHER INDICATIONS IN THE SAME SPC (not this page's indication, quoted for completeness): non-valvular atrial fibrillation 5 mg twice daily, reduced to 2.5 mg twice daily if at least two of age >= 80 years, body weight <= 60 kg, or serum creatinine >= 1.5 mg/dL (133 micromole/L), continued long-term; treatment of DVT/PE 10 mg twice daily for the first 7 days followed by 5 mg twice daily (maximum daily dose 20 mg for the first 7 days, then 10 mg); prevention of recurrent DVT/PE 2.5 mg twice daily started after completion of 6 months of treatment (maximum daily dose 5 mg). SWITCHING: from parenteral anticoagulants can be done at the next scheduled dose (do not administer simultaneously); from a vitamin K antagonist, stop the VKA and start apixaban when INR < 2; to a VKA, continue apixaban for at least 2 days after beginning VKA therapy and until INR >= 2. HEPATIC: contraindicated in hepatic disease associated with coagulopathy and clinically relevant bleeding risk; not recommended in severe hepatic impairment; caution in mild/moderate (Child Pugh A or B) but no dose adjustment required; perform liver function testing before initiating. PAEDIATRIC: no paediatric posology in the retrieved eMC §4.2 extract; the US label (openFDA §8.4) states 'Safety and effectiveness in pediatric patients have not been established.'

Dose adjustments

Renal

For prevention of VTE in elective hip or knee replacement surgery (VTEp), no dose adjustment is necessary in mild or moderate renal impairment. In severe renal impairment (creatinine clearance 15–29 mL/min) apixaban is to be used with caution for VTEp. In patients with creatinine clearance < 15 mL/min, or undergoing dialysis, there is no clinical experience and apixaban is not recommended. (Separate dose-reduction criteria apply in NVAF only — see adultDose notes.)

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to the active substance or to any of the excipients
Active clinically significant bleeding
Hepatic disease associated with coagulopathy and clinically relevant bleeding risk
Lesion or condition considered a significant risk factor for major bleeding — e.g. current or recent gastrointestinal ulceration, malignant neoplasms at high risk of bleeding, recent brain or spinal injury, recent brain, spinal or ophthalmic surgery, recent intracranial haemorrhage, known or suspected oesophageal varices, arteriovenous malformations, vascular aneurysms, or major intraspinal or intracerebral vascular abnormalities
Concomitant treatment with any other anticoagulant agent (unfractionated heparin, low molecular weight heparins, heparin derivatives such as fondaparinux, other oral anticoagulants) — except under specific circumstances of switching anticoagulant therapy, when UFH is given at doses necessary to maintain an open central venous or arterial catheter, or when UFH is given during catheter ablation for atrial fibrillation

Side effects

Haemorrhage and haematoma (common)
Contusion (common)
Anaemia (common)
Epistaxis (uncommon in VTEp; common in NVAF and VTEt)
Hypotension including procedural hypotension (uncommon in VTEp)
Thrombocytopenia (uncommon in VTEp)

Interactions

Other anticoagulants — concomitant treatment is contraindicated because of increased bleeding risk (SPC §4.3/§4.4)
Antiplatelet agents — concomitant use increases the risk of bleeding; following surgery, other platelet aggregation inhibitors are not recommended concomitantly with apixaban (SPC §4.4)
SSRIs, SNRIs and NSAIDs including acetylsalicylic acid — care is to be taken with concomitant treatment; in atrial fibrillation, concomitant ASA increased major bleeding from 1.8% to 3.4% per year (SPC §4.4)
Combined P-gp and strong CYP3A4 inhibitors (e.g. ketoconazole, itraconazole, ritonavir) increase apixaban blood levels — for patients receiving 2.5 mg twice daily, avoid coadministration; for 5 mg or 10 mg twice daily, decrease the dose by 50% (US label §7.1; eMC §4.5 was not captured in this bundle — verify against the UK SPC)
Combined P-gp and strong CYP3A4 inducers reduce apixaban blood levels — avoid concomitant use (US label §7.2). Clarithromycin: pharmacokinetic data suggest no dose adjustment is necessary (US label §7.1)

Clinical monograph

How it works

Apixaban directly and reversibly inhibits factor Xa, reducing thrombin generation and clot formation without requiring antithrombin.

Prescribing in practice

Bleeding is the principal risk, and the timing of the first postoperative dose relative to surgery and neuraxial anaesthesia/catheter removal must follow protocol to minimise bleeding and spinal haematoma risk.
Adjust use according to renal function and avoid in significant active bleeding or severe hepatic impairment with coagulopathy.
Numerous interactions occur with strong dual CYP3A4 and P-glycoprotein inhibitors or inducers and with other antithrombotic agents.

Monitoring

Monitor for clinical signs of bleeding, full blood count and renal function rather than routine coagulation assays, which do not reliably reflect its effect.

Counselling the patient

Take as prescribed for the full prophylaxis course and do not stop early, as the clot risk persists after surgery.
Report unusual bruising, prolonged bleeding, black stools or signs of leg swelling and breathlessness.

Evidence & guidelines

The ADVANCE trial programme demonstrated apixaban's efficacy and safety for VTE prophylaxis after major orthopaedic surgery, reflected in NICE VTE prophylaxis guidance.

Reference: ADVANCE-3 Trial (NEJM 2010); ADVANCE-2 Trial (Lancet 2010); NICE NG89; SPC Eliquis; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Drugs

Rivaroxaban (Stroke Prevention — AF) · Direct Oral Anticoagulant — Factor Xa Inhibitor

Pathways