Apixaban (Orthopaedic VTE Prophylaxis)

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.