Eliquis (apixaban) A new anticoagulant for treatment of Atrial Fibrillation

As seen in the Consultant Connection April 2013 Issue
By Cindy DeRan, R.Ph., CGP, Consultant Pharmacist, ICP, Inc.


 
In December 2012, Eliquis (apixaban), was approved by the FDA as a new molecular entity (NME) for prevention of strokes in patients with atrial fibrillation (A fib), not caused by a heart valve problem.  Eliquis will join Pradaxa (dabigatran) and Xaralto (rivaroxaban) as alternatives to warfarin (Coumadin and Jantoven) in reducing the risk of stroke.
 
People with atrial fibrillation (an irregular heart beat) are at an increased risk of forming a blood clot in the heart.  When your heart beats irregularly, it doesn’t pump blood as it should.  This can cause blood to pool in the upper chambers of your heart (called the atria).  This pooling can cause a blood clot to form in your heart.  A clot in your heart can break away and travel directly to your brain.  There, it can block an artery and cause a stroke.
Preventing blood clots from forming is probably the most important part of treating A fib.  The benefits of this type of treatment have been proven in multiple studies.  Doctors prescribe blood-thinning medicines, called anticoagulants, to stop clots by targeting factors your blood needs to form clots.
Warfarin is an anticoagulant that has been extensively studied and prescribed by doctors to help reduce the risk of stroke in people with A Fib since 1954.  To be sure you’re getting the right amount of warfarin, your doctor will do a test called a Prothrombin Time (“ProTime” or “PT.”)  By using an INR (International Normalized Ratio), your doctor can keep your blood clotting at a safe and effective level.
With the introduction of the new anticoagulants, dabigatran (Pradaxa), rivaroxaban (Xaralto), and apixaban (Eliquis), there are now alternatives to warfarin for the treatment of A Fib.  Unlike warfarin, there is no need for regular blood tests to see if your blood-thinning level is in the right range with these newer agents.  However, one of the major downsides to these agents is that there is no antidote to reverse bleeding.
With the recent addition of Eliquis (apixaban), there will be new debate about which anticoagulant is best to prevent strokes in patients with A fib.  There are advantages and disadvantages of the newer medications over warfarin.  Below is a table to help compare these agents.

 

Warfarin (Coumadin, Jantoven)
dabigantrim (Pradaxa)
Rivaroxaban (Xaralto)
Apixaban (Eliquis)
Mechanism
Vitamin K Antagonist
Direct Thrombin Inhibitor
Direct Factor Xa Inhibitor
Direct Factor Xa Inhibitor
Dosing
Once daily- with or without food
Two times each day- with or without food
Once or twice daily- with food at the same time each day
Twice daily
Regular blood tests (INR)
Yes
No
No
No
Renal function monitoring
No
Yes
Yes
Yes
Storage requirements
No
Dispense in original container. Discard after 4 months.
No
No
Dietary restrictions
Avoid foods high in Vitamin K, e.g. large amounts of leafy green vegetables and some vegetable oils. May need to avoid alcohol, cranberry juice, and products containing cranberries.
No
No
No
Antidote
Yes
No
No
No
Other
 
Causes dyspepsia in over 10% or patients.
Can cause dangerous bleeding. Stopping Xaralto increases your risk of having a stroke. Contraindicated in liver disease with bleeding risk.
Not recommended in severe hepatic impairment.
Choosing between the anticoagulants for atrial fibrillation is tricky.  When you have A. fib, you will need to work closely with your doctor to help choose the medication that has the most benefit with the least risk, to help reduce your risk of stroke.
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