Who should not use Eliquis?

Eliquis (apixaban) is an anticoagulant medication used to treat and prevent blood clots. It works by blocking factor Xa, which is involved in blood clotting. While Eliquis offers many benefits, it may not be suitable for everyone. This article provides an overview of who should not use Eliquis.

People with active bleeding

Eliquis is contraindicated in people who are currently bleeding or have conditions that predispose them to bleeding. This is because Eliquis works by preventing blood clotting, which can worsen bleeding episodes. Individuals with the following conditions should not take Eliquis:

• Active bleeding from trauma, surgery, gastrointestinal bleeding, or bleeding in the brain (hemorrhagic stroke)
• Bleeding disorders such as hemophilia
• Recent surgery on the brain, eyes, or spine
• Bleeding ulcers
• Vascular aneurysms or abnormalities
• Esophageal varices

Before initiating Eliquis, any excess risk of bleeding should be assessed. Eliquis should be discontinued at least 48 hours before invasive or surgical procedures to minimize bleeding risk.

People with prosthetic heart valves

Eliquis is not recommended for people who have prosthetic heart valves. This is because there is insufficient evidence on the efficacy and safety of Eliquis in this population.

Other anticoagulants like warfarin have been better studied and are preferred for preventing clot formation in prosthetic heart valves. Using Eliquis could lead to inadequate anticoagulation and thromboembolic complications in people with prosthetic valves.

People with antiphospholipid syndrome

Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by increased clotting. People with APS produce antibodies called antiphospholipid antibodies that make the blood sticky and prone to clotting.

There is limited data on using direct oral anticoagulants like Eliquis in APS patients. Eliquis may not be as effective as warfarin in preventing clots in people with APS. Unless other anticoagulants cannot be used, Eliquis should be avoided in APS patients with prior embolic events.

People with severe liver disease

Eliquis is metabolized by the liver. Severe hepatic impairment can increase blood levels of Eliquis, raising the risk of bleeding.

Eliquis is contraindicated in patients with:

• Child-Pugh class C liver cirrhosis
• Hepatic disease associated with coagulopathy leading to clinically relevant bleeding
• Liver enzymes ALT/AST > 2 x ULN combined with total bilirubin ≥ 1.5 x ULN

No dose adjustment is needed for mild or moderate liver disease. But caution is advised, and patients should be monitored closely.

People with severe kidney dysfunction

In patients with end-stage renal disease (ESRD) on dialysis, Eliquis blood levels may increase by up to 27%. While increased exposure may not have a significant impact in some patients, the bleeding risks with Eliquis have not been studied in ESRD.

It is recommended to avoid Eliquis in patients with CrCl Pregnant and breastfeeding women

There is limited data on using Eliquis during pregnancy. Animal studies showed no teratogenic effects, but potential risks in humans are unknown. Eliquis can cross the placenta after 20 weeks and may carry a risk of bleeding in the fetus.

Eliquis should be avoided in pregnant women unless alternative anticoagulants are unsuitable and the benefit outweighs potential risks. Women who become pregnant on Eliquis should switch to safer alternatives like heparin.

Small amounts of Eliquis can enter breastmilk. It is recommended to avoid breastfeeding while taking Eliquis or use alternate anticoagulants that are safer during lactation.

Children below 18 years

The safety and efficacy of Eliquis have not been established in children below 18 years. Eliquis is currently not recommended for use in the pediatric population.

People hypersensitive to Eliquis

Eliquis or its inactive ingredients can rarely cause hypersensitivity reactions like rash, hives, swelling, and itching. Individuals with known hypersensitivity to apixaban or its components should avoid using Eliquis.

Inactive ingredients in Eliquis

• Anhydrous lactose
• Microcrystalline cellulose
• Croscarmellose sodium
• Sodium lauryl sulfate
• Magnesium stearate

People taking strong dual inhibitors of CYP3A4 and P-gp

Eliquis is metabolized by the liver enzyme CYP3A4 and transported by P-glycoprotein (P-gp). Taking Eliquis with drugs that potently inhibit both CYP3A4 and P-gp can substantially increase Eliquis levels in the body.

Examples of strong dual inhibitors include:

• Antifungals like ketoconazole, itraconazole, voriconazole
• Antivirals like ritonavir
• Macrolide antibiotics like clarithromycin

The concomitant use of Eliquis with strong dual inhibitors of CYP3A4 and P-gp is contraindicated, as it may increase bleeding risk.

People taking other anticoagulants

Using Eliquis together with other blood thinners like heparin, warfarin, enoxaparin, dabigatran, or rivaroxaban may lead to additive anticoagulant effects and increase the risk of bleeding. Except in specific circumstances like switching between anticoagulants or during catheter ablation for atrial fibrillation, the concomitant use of Eliquis with other anticoagulants is contraindicated.

Conclusion

While Eliquis is an effective anticoagulant for many people, it is not suitable for everyone. It should be avoided in people with active bleeding, prosthetic heart valves, antiphospholipid syndrome, severe liver/kidney disease, pregnant/breastfeeding women, children

Condition Reason to Avoid Eliquis Active bleeding Can worsen bleeding Prosthetic heart valves Insufficient evidence of efficacy and safety Antiphospholipid syndrome May be less effective than warfarin Severe liver disease Increased bleeding risk from higher drug levels Severe kidney dysfunction Lack of safety data in end-stage renal disease Pregnancy and breastfeeding Potential fetal and neonatal bleeding risks Children under 18 years Safety and efficacy not established Hypersensitivity Risk of allergic reactions Strong dual inhibitors of CYP3A4 and P-gp Increased Eliquis levels and bleeding risk Other anticoagulants Additive anticoagulant effects

In patients undergoing catheter ablation for atrial fibrillation, heparin can be used concurrently with Eliquis. Eliquis should be discontinued at least 48 hours before ablation, and heparin bridging can be used during the peri-procedural period. Eliquis can be restarted after ablation once adequate hemostasis is achieved.

In patients switching anticoagulants, overlapping administration with both Eliquis and the other anticoagulant (e.g. warfarin) may be necessary for a short duration. This should be done cautiously under medical guidance to avoid excessive anticoagulation.

Overall, while Eliquis provides important benefits in treating and preventing blood clots in many patients, care must be taken to avoid its use in people where it may cause harm. Checking for contraindications, interacting drugs, comorbidities, and concomitant medications is essential before starting therapy with Eliquis. This enables maximizing the safe and effective use of this anticoagulant.

References

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