ApixabanNursing considerations

Side effects by what to assess

Sources: [1][2][3][4][5]

Body weight

Why

Dose selection in atrial fibrillation and children

When

Before starting; as children grow

Act on

60 kg or less counts toward the 2.5 mg twice-daily dose in AF

Sources: [1][2]

INR (prothrombin time)

Why

Timing a switch from warfarin; PT, INR, and aPTT do not measure apixaban effect

When

When converting from warfarin

Act on

Start apixaban once INR is below 2.0

Normal

INR 0.8 to 1.1 when not on a blood thinner. On warfarin, the usual target is 2.0 to 3.0.

Sources: [1][2][3]

Serum creatinine

Why

Dose selection in atrial fibrillation and pediatric renal limits

When

Before starting and when renal function changes

Act on

Creatinine 1.5 mg/dL or higher counts toward the 2.5 mg twice-daily dose

Normal

0.7 to 1.3 mg/dL in men and 0.5 to 0.95 mg/dL in women.

Sources: [1][2][3]

High-alert status

High-alert medication. Direct oral anticoagulants and factor Xa inhibitors, with apixaban named, are on the ISMP acute care high-alert list.

Sources: [1]

Narrow therapeutic index

The label does not describe a narrow therapeutic index or direct dosing by measured blood levels of the drug.

Sources: [1]

Boxed warning

Two warnings. (A) Stopping early raises the risk of clots and stroke; if it is stopped for any reason other than pathological bleeding or a finished course, cover with another anticoagulant. (B) Spinal or epidural hematoma, which can cause long-term or permanent paralysis, may occur with neuraxial anesthesia or spinal puncture. Risk rises with indwelling epidural catheters, other drugs affecting hemostasis, traumatic or repeated punctures, and prior spinal deformity or surgery. Monitor neurologic status often.

Sources: [1]

Antidote or reversal

Andexanet alfa reverses apixaban's anti-factor Xa effect in adults. Prothrombin complex concentrate or factor VIIa are options, though unstudied. Activated charcoal soon after ingestion lowers absorption. Hemodialysis does little, and protamine and vitamin K are not expected to work. The effect lasts at least 24 hours after the last dose.

Sources: [1][2]

Patient teaching

• Do not stop taking it without talking to the prescriber; stopping raises stroke risk
• Bleeding may take longer to stop, and bruising is easier
• Report unusual bleeding right away: pink, red, or brown urine; red or black stools; coughing or vomiting blood; severe headache or dizziness
• Tell doctors and dentists before any procedure, and before taking new drugs, aspirin, or NSAIDs
• After spinal or epidural anesthesia, report back pain, leg numbness or weakness, or bowel or bladder problems at once
• Tell the prescriber about pregnancy plans or breastfeeding

Sources: [1][2][3]

Sound-alike and look-alike names

None listed in the ISMP list of confused drug names.

Sources: [1]

Adult dose

Nonvalvular atrial fibrillation

5 mg twice daily. Use 2.5 mg twice daily if at least 2 of: age 80 or older, weight 60 kg or less, serum creatinine 1.5 mg/dL or higher.

DVT prophylaxis after hip or knee replacement

2.5 mg twice daily, first dose 12 to 24 hours after surgery. Hip: 35 days. Knee: 12 days.

Treatment of DVT or PE

10 mg twice daily for 7 days, then 5 mg twice daily.

Reduce recurrent DVT or PE

2.5 mg twice daily after at least 6 months of treatment.

Sources: [1]

Renal adjustment

Atrial fibrillation: reduce to 2.5 mg twice daily only when 2 of the 3 criteria apply (creatinine 1.5 mg/dL or more, age 80 or more, weight 60 kg or less). ESRD on hemodialysis: usual dose. VTE indications: no renal adjustment. Watch closely for bleeding.

Sources: [1][2]

Hepatic adjustment

Mild (Child-Pugh A): no change. Moderate (Child-Pugh B): no dosing recommendation because of limited experience and possible coagulation abnormalities. Severe (Child-Pugh C): not recommended.

Sources: [1]

Mechanism

Directly and selectively blocks factor Xa, both free and clot-bound, without needing antithrombin. Less thrombin is generated, so clots form and grow less. It has no direct effect on platelets. Peak levels come 3 to 4 hours after a dose, and the half-life is about 12 hours.

Sources: [1][2]