|Trade names||Eliquis, others|
|Defined daily dose||10 mg|
|Metabolism||CYP3A4, CYP3A5, CYP1A2 and others|
|Elimination half-life||9–14 h|
|Excretion||Bile (75%), kidney (25%)|
|Chemical and physical data|
|Molar mass||459.497 g·mol−1|
|3D model (JSmol)|
Apixaban, sold under the brand name Eliquis among others, is an anticoagulant medication used to treat and prevent blood clots and to prevent stroke in people with nonvalvular atrial fibrillation (AF). Specifically it is used to prevent blood clots following hip or knee replacement and in those with a history of prior clots. It is used as an alternative to warfarin and does not require monitoring by blood tests. It is taken by mouth.
Common side effects include bleeding and nausea. Other side effects may include bleeding around the spine and allergic reactions. Use is not recommended during pregnancy or breastfeeding. Use appears to be relatively safe in those with mild kidney problems. Compared to warfarin it has fewer interactions with other medications. It is a direct factor Xa inhibitor.
Apixaban was approved for medical use in the European Union in May 2011 and in the United States in December 2012. A month supply in the United Kingdom costs the NHS about £53 as of 2020. In the United States the wholesale cost of this amount is about $427. In 2017, it was the 93rd most commonly prescribed medication in the United States with more than eight million prescriptions. In December 2019, generic versions were approved in the United States.
Apixaban is indicated for the following:
- To lower the risk of stroke and embolism in people with nonvalvular atrial fibrillation.
- Deep vein thrombosis (DVT) prevention. DVTs may lead to pulmonary embolism (PE) in knee or hip replacement surgery patients.
- Treatment of both DVT and PE.
- To reduce the risk of recurring DVT and PE after initial therapy.
In the EU, apixaban is indicated for the prevention of venous thromboembolic events (VTE) in adults who have undergone elective hip or knee replacement surgery, the prevention of stroke and systemic embolism in adults with non-valvular atrial fibrillation (NVAF) with one or more risk factors, for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) in adults, and for the prevention of recurrent DVT and PE in adults.
Apixaban is recommended by the National Institute for Health and Clinical Excellence for the prevention of stroke and systemic embolism in people with non-valvular atrial fibrillation and at least one of the following risk factors: prior stroke or transient ischemic attack, age 75 years or older, diabetes mellitus, or symptomatic heart failure.
Apixaban and other anticoagulants (dabigatran, edoxaban and rivaroxaban) appear equally effective as warfarin in preventing non-hemorrhagic stroke in people with atrial fibrillation and are associated with lower risk of intracranial bleeding.
While apixaban may be used in people with severely decreased kidney function and those on hemodialysis it has not been studied in these groups.
|Treatment of VTE||10mg twice daily for 7 days, then 5mg twice daily||Usually continued for 6 months before changing treatment dose to preventive dose. The dose may need to be halved if taken at the same time as some other common drugs.|
|Prevent recurrent VTE||2.5mg twice daily after 6 months of full treatment|||
|Prevent VTE after knee replacement||2.5mg twice daily for 10-14 days starting 12-24 hours after surgery||Providing any bleeding after surgery has stopped.|
|Prevent VTE after hip replacement||2.5mg twice daily for 32-38 days starting 12-24 hours after surgery||Providing any bleeding after surgery has stopped.|
|Non-valvular AF||5mg twice daily||If one of the following: heart failure, hypertension, previous stroke, TIA, age ≥ 75, diabetes. Half the dose if 2 of the following: age ≥ 80, weight< 61kg, serum creatinine ≥ 133. Half the dose if person is also taking a potent inhibitor of both CYP3A4 and P-gp.|
The risk of bleeding is increased if apixaban is used at the same time as other blood thinners such as non steroidal anti-inflammatories, anti platelet drugs and heparin, or drugs that are a potent inhibitor of both CYP3A4 and P-gp (eg. ketoconazole, itraconazole, ritonavir). The blood thinning effect of apixaban might be reduced with rifampicin and phenytoin.
Apixaban can increase the risk of bleeding which may be serious and potentially fatal. Concurrent use with other medications that affect blood clotting can further increase this risk. This includes medications such as other anticoagulants, heparin, aspirin, antiplatelet medications, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and nonsteroidal anti-inflammatory drugs (NSAIDs).
Following spinal anesthesia or puncture people who are being treated with anti-thrombotic agents are at higher risk for developing a hematoma, which can cause long-term or permanent paralysis. The risk of this may be increased by using epidural or intrathecal catheters after a surgical operation or from the concurrent use of medicinal agents that affect hemostasis.
Mechanism of action
Apixaban is a highly selective, orally bioavailable, and reversible direct inhibitor of free and clot-bound factor Xa. Factor Xa catalyzes the conversion of prothrombin to thrombin, the final enzyme in the coagulation cascade that is responsible for fibrin clot formation. Apixaban has no direct effect on platelet aggregation, but by inhibiting factor Xa, it indirectly decreases clot formation induced by thrombin.
Apixaban was approved for medical use in the European Union in May 2011.
A new drug application (NDA) for the approval of apixaban was submitted to the U.S. Food and Drug Administration (FDA) by Bristol-Myers Squibb (BMS) and Pfizer jointly after conclusion of the ARISTOTLE clinical trial in 2011. Apixaban was approved for the prevention of stroke in people with atrial fibrillation on December 28, 2012. On March 13, 2014, it was approved for the additional indication of preventing deep vein thrombosis and pulmonary embolism in people who have recently undergone knee or hip replacement. On August 21, 2014, the FDA approved apixaban for the additional indication of the treatment of recurring deep vein thrombosis and pulmonary embolism. During its development the drug was known as BMS-562247-01. By late 2019, sales of the product by BMS accounted for thirty-percent of their quarterly revenue. In December 2019, the US FDA approved a generic version produced jointly by Mylan and Micro Labs.
Society and culture
As of 2020, a month supply of apixaban costs the NHS about £53 in the United Kingdom, where its cost reaches more than 50 times that of warfarin, although this difference may be offset by lower monitoring costs. In the United States the wholesale cost of this amount is about $427. In 2017, it was the 93rd most commonly prescribed medication in the United States with more than eight million prescriptions.
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