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Direct Oral Factor Xa Inhibitor — VTE / AF Stroke Prevention Pregnancy: Contraindicated — teratogenic in animals; use LMWH

Apixaban

Brand names: Eliquis

Adult dose

Dose: VTE treatment: 10 mg BD × 7 days, then 5 mg BD; VTE extended prophylaxis: 2.5 mg BD; AF stroke prevention: 5 mg BD (or 2.5 mg BD if 2+ of: age ≥80, weight ≤60 kg, creatinine ≥133 micromol/L); Hip replacement prophylaxis: 2.5 mg BD
Route: Oral
Frequency: Twice daily
Max: 10 mg BD (acute VTE phase); 5 mg BD (AF/maintenance VTE)
No food requirement for absorption. Antidote: andexanet alfa (licensed) for life-threatening bleeding. Tablets may be crushed and mixed with water or apple juice. AF dose reduction criteria: apply 2.5 mg BD if 2 of the 3 criteria met (not just one).

Paediatric dose

Route:
Seek specialist opinion — not routinely licensed in paediatrics

Dose adjustments

Renal

Avoid if CrCl <25 mL/min for VTE treatment; for AF: use 2.5 mg BD if creatinine ≥133 + one other criterion

Hepatic

Contraindicated in Child-Pugh B/C or coagulopathy

Clinical pearls

  • AMPLIFY trial: apixaban non-inferior to warfarin for VTE with significantly lower bleeding — now a first-line DOAC
  • ARISTOTLE trial: superior to warfarin for stroke prevention in AF with lower bleeding and lower mortality
  • Renal clearance only ~27% — most hepatically metabolised; better tolerated in moderate renal impairment vs dabigatran
  • Antidote: andexanet alfa — if unavailable, 4-factor PCC at 25–50 units/kg as alternative
  • AMPLIFY-EXT: 2.5 mg BD extended prophylaxis reduces recurrent VTE with similar bleeding to placebo — option for extended treatment

Contraindications

  • Active significant bleeding
  • Severe hepatic impairment
  • Prosthetic heart valves
  • Pregnancy
  • Concurrent strong dual inhibitors of CYP3A4 and P-gp

Side effects

  • Bleeding
  • Anaemia
  • Bruising
  • Nausea
  • Elevated LFTs

Interactions

  • Strong CYP3A4 + P-gp inhibitors (ketoconazole, itraconazole, ritonavir) — increase levels significantly
  • Strong inducers (rifampicin, phenytoin, carbamazepine) — reduce levels
  • Antiplatelets/NSAIDs — additive bleeding

Monitoring

  • Renal function and LFTs at baseline and annually
  • FBC
  • Signs of bleeding

Reference: BNFc; BNF 90; AMPLIFY Trial; ARISTOTLE Trial; NICE TA341 (Apixaban for VTE); NICE TA275 (Apixaban for AF). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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