Apixaban: prophylaxis of stroke and systemic embolism

NHS Borders Protocol for Apixaban in prophylaxis of stroke and systemic embolism in Non Valvular Atrial Fibrillation

1. Drug: Apixaban 2.5mg and 5mg tablets.

2 NHS Borders formulary indication

First choice direct oral anticoagulant (DOAC) in prevention of stroke and systemic embolism in
adult patients with non-valvular atrial fibrillation, with one or more risk factors, such as congestive heart failure, hypertension, age ≥ 65 years, diabetes mellitus, prior stroke or transient ischaemic attack (TIA).

3. Dose:

5mg twice daily.
2.5mg twice daily if at least two of the following three criteria:
- age ≥ 80 years, bodyweight ≤60kg or serum creatinine ≥133micromol/L
Or
if creatinine clearance 15-29 mL/min
- avoid if creatinine clearance < 15ml/minute, or in dialysed patients.

4. Cautions/contra-indications/drug interactions:

• Do not use for patients with creatinine clearance < 15ml/min.
• All patients being considered for Apixaban should be assessed for “bleeding risk”, including
  PMH of upper gastrointestinal haemorrhage or upper GI symptoms, and if risk is deemed to
  be high, alternative anticoagulation should be considered.
• Concomitant use of Apixaban with antiplatelet agents increases risk of bleeding; refer to East
  Region Formulary guidance on co-prescription of antiplatelets with oral anticoagulation for
  information.
• For patients at risk of ulcerative gastrointestinal disease prophylactic, treatment with an oral
  PPI should be considered.
• If an invasive procedure or elective surgical intervention is required, Apixaban should be
  stopped at least 24 - 48 hours before the intervention, if possible - based on the clinical
  judgment of the physician and the risk of bleeding. If the procedure cannot be delayed, the
  increased risk of bleeding should be assessed against the urgency of the intervention.
• Apixaban should be restarted as soon as possible after the invasive procedure or surgical
  intervention, provided the clinical situation allows and adequate haemostasis has been
  established.
• Refer to SPC and BNF for further information.

5. Patient counselling: (Documented in notes/on medicines chart)

• Ensure patient is aware of potential adverse reactions - patients should be counselled on
  the symptoms and signs of bleeding and an information booklet supplied.
• Ensure that patient understands the prescribed dose to take.

6. Monitoring – patient safety:

• Monitor creatinine clearance regularly in patients with renal impairment.

7. Switching from Apixaban to Warfarin:

• Continue administration of Apixaban for at least 2 days after commencing Warfarin.
• Check INR after 2 days of co-administering Warfarin and Apixaban
• Continue co-administration of Warfarin and Apixaban until INR is 2.0 or above
• Stop Apixaban when INR > 2.0.

Switching from Warfarin to Apixaban:

• Discontinue Warfarin and start Apixaban when INR is < 2.0