Apixaban: prophylaxis of stroke and systemic embolism - NHS Borders

Drug:

Apixaban 2.5mg and 5mg tablets (licensed and recommended for stroke and systemic embolism prophylaxis in non-valvular atrial fibrillation (AF)).

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).

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 (cautious use with regular monitoring of Us&Es)

- avoid if creatinine clearance < 15ml/minute, or in dialysed patients.

1. Do not use for patients with creatinine clearance < 15ml/min.
   
   
2. There is no contraindication to using apixaban in patients with mild or moderate aortic valve disease.
   
   
3. These patients should be managed using this apixaban protocol.
   
   
4. Patients with severe aortic stenosis or regurgitation should be evaluated individually, but anticoagulation choice should generally follow the same principles unless mechanical valves or rheumatic mitral stenosis are present.
   
   
5. 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.
   
   
6. Concomitant use of Apixaban with antiplatelet agents increases risk of bleeding; antiplatelets should always be reviewed when apixaban (or other OAC) is commenced and indication and duration of treatment (from the specialist team) should be documented in medical notes and in the discharge eDL or any other relevant document.
   
   
7. For patients at risk of ulcerative gastrointestinal disease prophylactic, treatment with an oral PPI should be considered.
   
   
8. If an invasive procedure or elective surgical intervention is required, Apixaban should be stopped at least 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.
   
   
9. 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.
   
   
10. Refer to SPC and BNF for further information.

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.

• Monitor creatinine clearance regularly in patients with renal impairment.

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.