Treatment Name: Apixaban (Eliquis®)

Apixaban (Eliquis®) is a Supportive Care Therapy to prevent or treat Blood Clots

How does apixaban (Eliquis®) work?
Apixaban is designed to help your body eliminate blood clots by blocking the action of a specific clotting factor known as Factor Xa (“factor ten-A”).

By blocking clotting Factor Xa, your body breaks down the clot faster than it can build it. This is known as anticoagulation treatment.

Goals of therapy:
Apixaban is taken to treat large blood clots that are harmful to your body, for example: those in the lungs, heart, or brain, or those that cause swelling or pain in the arms or legs.

Apixaban (Eliquis®) is available by doctor's prescription only.

Schedule

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Usual apixaban (Eliquis®) starting dose to treat a blood clot in the veins (Deep-Vein Thrombosis, DVT) or lungs (Pulmonary Embolism, PE):

  • Apixaban 10 mg (two 5 mg oral tablets) by mouth twice daily for 7 consecutive days, then
  • Apixaban 5 mg oral tablet by mouth twice daily continuously
    • Apixaban may be taken with or without food

If you miss a morning dose, take the missed dose as soon as possible on the same day, and resume taking apixaban at your normal time in the evening. Do not double the dose to make up for the missed dose. If you miss the evening dose, resume the normal dosing schedule in the morning the following day.

It can take a long time for your body to break down and get rid of a blood clot.

  • Most cancer patients who develop a clot are treated 3 to 6 months
  • May be continued until cancer is gone
  • Your doctor may recommend apixaban with no stopping point

For patients taking apixiban without an end date, after at least 6 months of therapy, your doctor may decide to reduce the dose of apixaban to 2.5 mg by mouth twice daily depending upon your history of clots, ongoing risk factors for blood clots, whether you are having side effects from apixaban, as well as other medications you are taking.

Do not run out of apixaban tablets. Be sure to refill your prescription before you take your last pill. If you stop taking apixaban (Eliquis®) before your doctor says that it is okay to stop taking it, there may be an increased risk of the blood clot getting worse or increased risk of developing new blood clots. Talk to your doctor before suddenly discontinuing apixaban therapy.

Note: Your doctor may choose to shorten or lengthen the amount of time you stay on therapy due to certain factors specific to your case based upon the perceived risks and benefits.

Side Effects

In the prescribing label information (apixaban package insert), the most commonly reported side effects from apixaban (Eliquis®) are shown here. The exact percentages of patients that will experience apixaban side effects is unknown because it has been used under a wide variety of patient populations in many different clinical trials:

A note about side effect percentages

*In clinical trials, 9 - 12% of patients had a bleeding event that was considered a minor bleed, 3 - 4% had a non-major bleeding event, but did require hospitalization or evaluation by a doctor, and less than 1% had a bleed that was considered a major or life threatening bleeding event.

If you have any signs of bleeding while taking apixaban, you should call your doctor immediately or go to an emergency room.

Apixaban should be used in pregnant women only if the potential benefits to the mother outweigh the potential risks to the unborn baby. Treatment may increase the risk of bleeding in both the mother and the baby, and increase the risk of bleeding during delivery. Additionally, it is unknown if apixaban is excreted in human breast milk, therefore women should either discontinue breastfeeding or discontinue using apixaban.

Importantly, not all people who experience a side effect from Eliquis® (apixaban) will experience it in the same way. It may be mild in some or severe in others, depending upon the individual. Everybody is different. Additionally, side effects may vary over time. For some, side effects may be a reason to delay or switch treatment, reduce the dose, or avoid future treatment with a certain medication altogether.

After starting treatment with Eliquis® (apixaban), be sure to come back and watch all of the side effect videos shown below. Each of these videos contain valuable information about side effect management that will hopefully help you to both feel better and stay out of the hospital.

Side effect videos Side Effect Videos
BleedingBleedingBlood ClotsBlood Clots

Monitoring

How often is monitoring needed?
Labs (blood tests) may be checked before treatment and periodically during treatment until stable. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), or basic metabolic panel (BMP), plus any others your doctor may order.

How often is imaging needed?
Imaging is checked before treatment to diagnose the presence of a blood clot. Imaging may include: computerized tomography angiography (CT angiogram or CTA) scans, ventilation/perfusion (VQ) scan, or ultrasounds of arms or legs (also known as venous dopplers). Typically, if a blood clot is found on any of the above imaging techniques, it is not routinely repeated after starting therapy to see if the blood clot has gone away.

Other imaging such as magnetic resonance imaging (MRI) or computerized tomography (CT) scans may be checked during treatment if there is a concern for bleeding into certain organs or tissues.

How might blood test results/imaging affect treatment?
Depending upon the results, your doctor may advise to continue apixaban as planned, reduce the dose of future treatments, delay the next dose until the side effect goes away, or switch to an alternative therapy.

Note: Clotting tests such as the prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (aPTT) are not useful for monitoring the anticoagulant effect of apixaban.

Questions to Ask Your...

A better understanding of your treatments will allow you to ask more questions of your healthcare team. We then hope that with the answers, you will get better results and have greater satisfaction with your care. Because we know it's not always easy to know what questions to ask, we've tried to make it easy for you!

Choose any healthcare provider below to see common questions that you may want to ask of this person. Then, either print each list to bring to your clinic visits, or copy the questions and send them as a message to your healthcare team through your electronic medical record.

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Questions to ask your DoctorNursePharmacist

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        Questions to ask your NurseDoctorPharmacist

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              Questions to ask your PharmacistDoctorNurse

                    ChemoExperts Tips

                    • You may bruise more easily and it may take longer to stop bleeding from simple cuts and scrapes
                    • Tell your dentist that you are taking apixaban in order to prevent excessive bleeding during dental procedures
                    • Apixaban may need to be temporarily held before and after a surgery or invasive procedure if their is a risk of bleeding. It may also need to be temporarily held to reduce the risk of bleeding if your platelet count is too low 
                    • Tell your doctor if you have a known bleeding disorder before you start treatment with apixaban
                    • If you have trouble swallowing apixaban tablets, they may be crushed and mixed with apple juice, applesauce, or water and swallowed immediately. Mix the crushed tablets in a small amount of liquid or applesauce to be sure that you can swallow the whole dose
                    • The risk of a spinal hematoma (fluid collection made up of blood) in patients taking apixaban may be increased during a lumbar pucture (spinal tap). Tell your doctor and pharmacist that you are taking apixaban before a lumbar puncture is performed so that you can discuss if temporarily holding apixaban therapy (miss one or more doses) before or after the procedure would reduce the risk of bleeding
                    • Talk to your doctor or pharmacist before taking any over-the-counter (OTC) pain medications such as ibuprofen (Advil® or Motrin®), naproxen (Aleve®), and aspirin as these medications can increase the risk of bleeding when taken with apixaban. Apixaban is NOT usually taken with other anticoagulants
                    • Certain antidepressants such as “Selective Serotonin Reuptake Inhibitors, or SSRIs”, or antiplatelet medications such as clopidogrel (Plavix®) can increase the risk of bruising or bleeding when taken with apixaban
                    • May interact with certain antifungal, antiviral, and seizure medications that may either increase the blood levels of apixaban and increase risk of bleeding or decrease blood levels and decrease the effectiveness of apixaban
                    • Store apixaban (Eliquis®) at room temperature between 68°F to 77°F
                    • A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately. When taken with certain medications, the dose of apixaban may need to be decreased to prevent bruising or bleeding

                    Patient Assistance & Co-payment Coverage

                    Patients under the age of 65 years, or those with private insurance plans:
                    If you have insurance and are looking for patient assistance or copay assistance for Apixaban (Eliquis®), we have provided links that may help.

                    Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for Apixaban (Eliquis®). Depending upon your income, they may be able to help cover the cost of:

                    • Apixaban (Eliquis®)

                    For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.

                    • If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.

                    Medicare and Medicaid patients (Patients 65 years or older):
                    The clinic providing treatment will likely pre-authorize medications and immune therapies such as Apixaban (Eliquis®) and are the best source to help you understand drug cost.

                    • Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.

                    References

                    1) Apixaban (Eliquis®) prescribing label information. Apixaban (Eliquis®) package insert.

                    Created: October 22, 2017 Updated: January 15, 2020

                    What is Blood Clots?

                    To stop bleeding when an injury occurs, platelets along with a complex system of proteins called the "coagulation cascade," are activated to start the formation of blood clots when an injury occurs.

                    Cancer can cause the coagulation cascade to be active even when there is no injury present. These clots most commonly form in the large veins of the arms or legs (deep vein thrombosis) and can break off and travel to the lungs (pulmonary embolism), heart (myocardial infarction), or brain (thrombotic stroke).

                    Medications can decrease the risk of a harmful clot from forming. When an unwanted blood clot does form, medications need to be given to stop the clot from getting bigger while your body breaks down the existing clot. These medications either slow down the activity of proteins in the coagulation cascade or decrease the amount of clotting factor proteins in the blood.

                    NOTE: Treatment Options listed below are not all-inclusive. Other treatments may be available. ChemoExperts provides drug information and does not recommend any one treatment over another. Only your Doctor can choose which therapy is appropriate for you.

                    What is a CBC?

                    A Complete Blood Count (CBC) is a frequently ordered blood test that tells clinicians the status of your: 1) White blood cell count, 2) Hemoglobin, and 3) Platelet count at the time the test was taken.

                    Common uses:
                    1) White blood cell count (WBC): is used to determine infection risk, or response to chemotherapy. Certain chemotherapy agents may harm our good infection-fighting cells. Sometimes chemotherapy may need to be delayed to allow these cells to recover.

                    2) Hemoglobin: is used to determine if someone is anemic. Anytime the hemoglobin is below 12 g/dL, the person is said to be anemic. Red blood cell transfusions, and sometimes iron can be given to restore the hemoglobin level, but anemia treatment should always aim at treating the underlying cause or condition.

                    3) Platelet count: is used to determine if the risk of bleeding is increased or if a platelet transfusion is required to prevent bleeding. Certain medications that increase bleeding risk, such as: aspirin, certain chemotherapy agents, and blood thinners, may need to be stopped temporarily until the platelet count is within a safe range.

                    What is a CMP?

                    A Comprehensive Metabolic Panel (CMP) is a frequently ordered blood test that tells clinicians the status of your: 1) Electrolytes & Acid/Base status, 2) Kidney function, 3) Liver function, 4) Blood sugar, and 5) Calcium at the time the test was taken. It is commonly used to monitor liver and kidney function when beginning new medications such as chemotherapy. A total of 14 tests are run simultaneously and are shown below.

                    Electrolytes & Acid/Base status:
                    1) Sodium, 2) Potassium, 3) Carbon dioxide, 4) Chloride

                    Kidney Function:
                    5) BUN (blood urea nitrogen), 6) Serum creatinine (Scr)

                    Liver Function:
                    7) AST, 8) ALT, 9) Total bilirubin, 10) Alk Phos, 11) Albumin, 12) Total protein

                    Blood sugar:
                    13) Serum glucose

                    Calcium:
                    14) Serum calcium

                    A note about side effect percentages

                    The number you see next to the percent sign (%) means how many people out of 100 are likely to experience this side effect.

                    For example, if the side effect is reported to occur in 8% of patients, this means that roughly 8 out of 100 people receiving this treatment will experience this side effect.