Apixaban is an oral, direct factor Xa inhibitor (a “DOAC”/“NOAC”) used to prevent and treat thromboembolic disease. By selectively and reversibly inhibiting free and clot-bound factor Xa, apixaban blocks the central step of the coagulation cascade where prothrombin is converted to thrombin. The result is reduction of fibrin clot formation and thrombin-mediated amplification of coagulation. Unlike warfarin, apixaban does not require routine INR monitoring and has fewer food/drug restrictions, while providing rapid onset, predictable anticoagulant effect, and short half-life supportive of temporary interruption for procedures.
Across randomised trials and large real-world registries, apixaban has demonstrated non-inferiority or superiority versus warfarin for stroke prevention in non-valvular atrial fibrillation (NVAF) and for treatment/secondary prevention of venous thromboembolism (VTE), with lower rates of major bleeding in many settings (notably intracranial haemorrhage). Dose individualisation is essential; under-dosing risks thrombosis, whereas excess dosing increases bleeding. Patient counselling should emphasise adherence to the twice-daily schedule, recognition of bleeding signs, and when to seek urgent care.
Apixaban’s oral bioavailability is ≈50%; peak effect occurs 3–4 hours post-dose. Elimination is multi-pathway (renal ~27%, hepatic metabolism via CYP3A4/5, and biliary/intestinal secretion via P-glycoprotein/BCRP). Consequently, clinically relevant interactions occur with strong dual inhibitors or inducers of CYP3A4 and P-gp. An approved reversal agent (andexanet alfa) is available in many European countries for life-threatening or uncontrolled bleeding related to apixaban or rivaroxaban; when unavailable or unsuitable, four-factor prothrombin complex concentrate (4F-PCC) may be considered under specialist guidance.
Apixaban is not appropriate for patients with mechanical heart valves and is generally avoided in moderate–severe rheumatic mitral stenosis. For procedures, stopping intervals depend on bleeding risk and kidney function; most low-risk procedures require 24 hours’ interruption, while high-risk surgeries need 48 hours or longer. Peri-operative plans should be formalised by the managing team.
All anticoagulants balance bleeding risk against thrombotic protection. Selection and duration are individualised using validated scores (e.g., CHA2DS2-VASc, HAS-BLED) and clinical judgement.
Bleeding is the principal adverse effect of apixaban. The overall major-bleeding risk is typically lower than with warfarin in comparable populations, but any unexpected or severe bleeding requires urgent assessment. Non-haemorrhagic adverse reactions are usually mild and non-specific.
Any head injury while anticoagulated warrants clinical assessment (often including CT head), even if symptoms seem mild.
Regular medication reconciliation is important to avoid inadvertent co-therapy with interacting agents or duplicate anticoagulation.
Apixaban is a substrate of P-glycoprotein (P-gp) and CYP3A4. Interactions chiefly arise from agents that strongly inhibit or induce these pathways or that independently increase bleeding risk.
Action: Many EU labels advise avoidance or careful use with dose reduction only when clearly allowed by local SmPC. Consider alternative antibiotic/antifungal or switch anticoagulant with specialist input.
Action: Avoid combination; consider warfarin or a different regimen where monitoring is possible.
Provide an updated medication/supplement list at every visit. Alert pharmacists and dentists before new prescriptions or procedures.
Missed dose: Take it as soon as remembered on the same day, then resume the regular twice-daily schedule. Do not take two doses at once to make up for a missed dose.
Accidental double dose: If two doses are taken close together, there is increased bleeding risk. Avoid activities that could cause injury, monitor for bleeding (nose, gums, urine, stools, unusual bruising), and contact a clinician/pharmacist for advice—particularly in elderly, low-weight, or renal-impaired patients.
Suspected overdose or serious bleeding: Seek emergency care immediately. Bring the medication list/pack. Management is guided by severity, timing of last dose, renal/hepatic function, and availability of reversal agents.
After stabilisation, reassess the ongoing indication and timing for restart of anticoagulation, balancing thrombotic and bleeding risks (often 3–7 days after controlled GI bleeding; later after intracranial haemorrhage—specialist decision).
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