Eliquis

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Eliquis on Prescriptsy

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Eliquis is the brand name for apixaban, a direct oral anticoagulant (DOAC) manufactured by Bristol-Myers Squibb and Pfizer.

It is licensed in the United Kingdom for the prevention of stroke and systemic embolism in adults with non-valvular atrial fibrillation (AF), the treatment and secondary prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE), and the prevention of venous thromboembolism (VTE) following elective hip or knee replacement surgery.

Apixaban belongs to the class of direct factor Xa inhibitors, which have largely replaced warfarin as first-line oral anticoagulants in many clinical settings due to their predictable pharmacokinetics, fixed dosing, and reduced need for monitoring.

Atrial fibrillation affects approximately 1.5 million people in the UK and is the most common sustained cardiac arrhythmia.

Without anticoagulation, AF increases the risk of ischaemic stroke by approximately fivefold.

Venous thromboembolism, encompassing DVT and PE, affects approximately 1 in 1,000 adults per year in the UK and is a significant cause of preventable hospital death.

This page provides a comprehensive clinical overview of Eliquis, including its mechanism of action, clinical evidence, dosing for each indication, side effects, safety warnings, drug interactions, and how to obtain a prescription in the UK.

Important safety information about Eliquis

Before reading further, note the following essential safety points about Eliquis.

• Eliquis increases the risk of bleeding. Seek urgent medical advice for any signs of unusual or heavy bleeding, including blood in the urine, black stools, prolonged nosebleeds, or coughing up blood.
• Do not stop taking Eliquis without medical advice. Stopping anticoagulation prematurely increases the risk of stroke in patients with atrial fibrillation and recurrent blood clots in patients with VTE.
• Carry an anticoagulant alert card at all times and inform all healthcare professionals (including dentists, pharmacists, and emergency staff) that you are taking Eliquis.
• Avoid non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen unless specifically advised by your prescriber, as they increase bleeding risk.

What is anticoagulation and why is it needed

Anticoagulation is the use of medication to reduce the blood's tendency to form clots.

While blood clotting is a vital protective mechanism that prevents excessive bleeding after injury, abnormal clot formation within blood vessels (thrombosis) can cause life-threatening conditions.

In atrial fibrillation, turbulent blood flow within the atria promotes the formation of clots that may travel to the brain and cause ischaemic stroke.

In venous thromboembolism, clots form in the deep veins of the legs (DVT) and may break away and travel to the lungs (PE), which can be fatal.

Anticoagulant medications reduce the risk of these thrombotic events by interrupting specific steps in the coagulation cascade.

Traditional anticoagulants such as warfarin and heparin have been used for decades, but DOACs including apixaban now offer a more convenient and, in many respects, safer alternative for appropriate patients.

How Eliquis works: mechanism of action

Apixaban is a potent, oral, reversible, and highly selective direct inhibitor of factor Xa (FXa).

Factor Xa is a serine protease that sits at the convergence of the intrinsic and extrinsic coagulation pathways, catalysing the conversion of prothrombin (factor II) to thrombin (factor IIa) within the prothrombinase complex.

Thrombin is the key effector enzyme of coagulation, responsible for converting fibrinogen to fibrin, activating platelets, and amplifying the coagulation cascade through positive feedback loops.

By inhibiting factor Xa, apixaban reduces thrombin generation in a dose-dependent manner, decreasing fibrin clot formation without directly affecting existing clots.

This distinguishes it from thrombolytic agents, which actively break down clots.

Apixaban inhibits both free factor Xa and factor Xa bound within the prothrombinase complex, as well as clot-bound factor Xa, providing effective anticoagulation without the need for antithrombin III as a cofactor (unlike heparins).

Apixaban is rapidly absorbed after oral administration, reaching peak plasma concentrations within 3 to 4 hours.

Its oral bioavailability is approximately 50% and is not significantly affected by food. The terminal half-life is approximately 12 hours, supporting twice-daily dosing for consistent anticoagulant effect.

Apixaban is metabolised primarily by CYP3A4 and is a substrate for P-glycoprotein, which has implications for drug interactions.

Approximately 25% of the dose is excreted renally, with the remainder eliminated via the hepatobiliary and intestinal routes.

Clinical evidence and national guidelines

Stroke prevention in atrial fibrillation: the ARISTOTLE trial

The landmark ARISTOTLE trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) randomised over 18,000 patients with AF and at least one additional stroke risk factor to receive either apixaban 5 mg twice daily or warfarin (titrated to an INR of 2.0 to 3.0).

The results, published in the New England Journal of Medicine in 2011, demonstrated that apixaban was superior to warfarin for the prevention of stroke and systemic embolism (relative risk reduction 21%), caused significantly less major bleeding (relative risk reduction 31%), and was associated with lower all-cause mortality (relative risk reduction 11%).

The rate of intracranial haemorrhage, the most feared complication of anticoagulation, was 58% lower with apixaban than with warfarin.

Treatment of VTE: the AMPLIFY trial

The AMPLIFY trial compared apixaban (10 mg twice daily for 7 days followed by 5 mg twice daily for 6 months) with conventional therapy (enoxaparin followed by warfarin) for the treatment of acute DVT or PE.

Apixaban was non-inferior to conventional therapy for the primary efficacy outcome of recurrent VTE or VTE-related death, while causing significantly less major bleeding (relative risk reduction 69%).

The AMPLIFY-EXT trial subsequently showed that extended secondary prevention with apixaban 2.5 mg twice daily significantly reduced recurrent VTE compared with placebo without a significant increase in major bleeding.

UK guidelines

NICE Technology Appraisals TA275 (apixaban for preventing stroke in AF) and TA341 (apixaban for the treatment and secondary prevention of DVT and PE) recommend apixaban as a clinical and cost-effective option.

NICE Clinical Guideline CG180 on atrial fibrillation recommends offering anticoagulation with a DOAC (in preference to warfarin) to all patients with a CHA2DS2-VASc score of 2 or more.

The Scottish Medicines Consortium (SMC) has also accepted apixaban for these indications.

NHS England has supported the widespread adoption of DOACs, and apixaban is now the most prescribed oral anticoagulant in the UK.

Dosage and administration by indication

Stroke prevention in non-valvular atrial fibrillation

The standard dose is 5 mg taken orally twice daily.

Dose reduction to 2.5 mg twice daily is required for patients meeting at least two of the following three criteria: age 80 years or older, body weight 60 kg or less, or serum creatinine of 133 micromol/L or above.

This dose reduction is based on pharmacokinetic modelling and the ARISTOTLE subgroup analyses, which showed consistent efficacy and safety across patient subgroups.

Treatment of DVT and PE

The initial treatment dose is 10 mg twice daily for the first 7 days, followed by 5 mg twice daily.

The minimum recommended treatment duration is 3 months for provoked VTE (where a transient risk factor has been identified, such as recent surgery or immobilisation).

For unprovoked VTE or where the risk of recurrence is high, longer or indefinite treatment may be recommended following a shared decision-making discussion with the patient.

Extended secondary prevention of VTE

After completing at least 6 months of treatment for DVT or PE, a reduced dose of 2.5 mg twice daily may be used for long-term secondary prevention in patients who remain at risk of recurrence but also have risk factors for bleeding.

VTE prevention after elective hip or knee replacement

The recommended dose is 2.5 mg twice daily, starting 12 to 24 hours after surgery.

The duration of thromboprophylaxis is 32 to 38 days for total hip replacement and 10 to 14 days for total knee replacement, reflecting the differing periods of highest VTE risk for each procedure.

Practical dosing advice

Eliquis tablets may be taken with or without food.

For patients who have difficulty swallowing, the tablet may be crushed and suspended in water or 5% glucose solution, or mixed with apple sauce, and administered immediately.

If a dose is missed, it should be taken as soon as possible on the same day and the regular twice-daily schedule resumed.

A double dose should never be taken to compensate for a missed dose.

Side effects of Eliquis

Common side effects

Bleeding is the most common adverse effect associated with Eliquis and reflects its intended pharmacological action.

The most frequently reported bleeding events include bruising (ecchymosis), nosebleeds (epistaxis), haematuria, gingival bleeding, gastrointestinal bleeding (which may present as blood in stools, dark stools, or abdominal pain), haematoma, and prolonged bleeding from minor cuts or wounds.

In the ARISTOTLE trial, the annual rate of major bleeding with apixaban was 2.13% compared with 3.09% with warfarin.

Uncommon side effects

Nausea, anaemia (from chronic occult blood loss), hypotension, and mildly elevated liver transaminases have been reported. Allergic reactions including rash, pruritus (itching), and rarely angioedema may occur.

Thrombocytopenia (reduced platelet count) is uncommon but should be investigated if unexplained bruising or bleeding occurs.

Rare but serious side effects

Major haemorrhage requiring hospitalisation, blood transfusion, surgical intervention, or resulting in death is the most serious risk.

Intracranial haemorrhage (bleeding within the brain) is the most dangerous form and may present as sudden severe headache, confusion, visual disturbance, weakness on one side, difficulty speaking, or loss of consciousness.

Spinal or epidural haematoma may occur in patients undergoing neuraxial anaesthesia or spinal puncture, potentially resulting in long-term neurological impairment including paralysis.

Retroperitoneal haemorrhage, haemoptysis (coughing up blood), and haemarthrosis (bleeding into joints) are rare but reported.

When to seek emergency help

Call 999 or attend A&E immediately if you notice blood in your urine (pink, red, or dark brown), black tarry stools or fresh blood in your stools, vomiting blood or material that looks like coffee grounds, severe or prolonged nosebleeds that do not stop after 15 minutes of continuous pressure, heavy or unusual bruising, bleeding from wounds that will not stop, sudden severe headache, sudden confusion or difficulty speaking, sudden weakness or numbness on one side of the body, sudden visual disturbance, or collapse.

These may be signs of serious bleeding or stroke requiring emergency treatment.

Warnings and precautions

Bleeding risk assessment

Before prescribing Eliquis, clinicians assess the individual's bleeding risk using tools such as the HAS-BLED score.

Risk factors for bleeding include older age, low body weight, renal impairment, hepatic impairment, previous history of gastrointestinal bleeding, concomitant use of antiplatelet agents or NSAIDs, and uncontrolled hypertension.

The decision to anticoagulate balances the stroke prevention benefit (assessed using CHA2DS2-VASc for AF) against the bleeding risk.

Renal and hepatic impairment

Approximately 25% of apixaban is excreted by the kidneys.

In patients with mild to moderate renal impairment (creatinine clearance 30 to 80 mL/min), no dose adjustment is required beyond the dose reduction criteria described above.

In severe renal impairment (creatinine clearance 15 to 29 mL/min), Eliquis should be used with caution. It is not recommended for patients with creatinine clearance below 15 mL/min.

Eliquis is contraindicated in severe hepatic impairment (Child-Pugh C) and should be used with caution in mild to moderate hepatic disease.

Do not stop Eliquis without medical advice

Premature discontinuation of anticoagulation significantly increases the risk of stroke in patients with AF and recurrent VTE in patients being treated for DVT or PE.

If Eliquis needs to be stopped for surgery, the interruption should be as short as possible and managed according to a perioperative bridging protocol agreed with the surgical and medical teams.

Anticoagulant alert card

All patients taking Eliquis should carry an anticoagulant alert card and inform all healthcare professionals, including dentists, pharmacists, podiatrists, and emergency staff, that they are taking an anticoagulant.

In an emergency, this information is critical for guiding treatment decisions, particularly if surgery or a thrombolytic agent is being considered.

Drug interactions

Apixaban is metabolised by CYP3A4 and is a substrate for P-glycoprotein (P-gp).

Strong dual inhibitors of CYP3A4 and P-gp, including systemic ketoconazole, itraconazole, voriconazole, and ritonavir, significantly increase apixaban plasma levels and are not recommended.

Strong dual inducers of CYP3A4 and P-gp, including rifampicin, phenytoin, carbamazepine, phenobarbital, and St John's wort, reduce apixaban levels and may decrease efficacy; concomitant use is not recommended.

Concomitant use of other anticoagulants, antiplatelet agents, NSAIDs, SSRIs, and SNRIs increases bleeding risk and requires careful clinical assessment.

How to get an Eliquis prescription in the UK

Eliquis is a prescription-only medicine (POM) in the UK.

It is most commonly initiated by a hospital consultant (cardiologist, haematologist, or acute medicine physician) following diagnosis of AF, DVT, or PE, or in the perioperative setting for VTE prophylaxis.

Once initiated, ongoing prescriptions are typically managed by the patient's GP. Authorised online prescribers may also issue prescriptions for patients with established diagnoses who require repeat supply.

The standard NHS prescription charge in England is currently 9.90 pounds per item. Prescriptions are free for all patients in Scotland, Wales, and Northern Ireland.

Patients with certain medical exemptions, including those aged 60 and over, may be entitled to free prescriptions in England.

Living with anticoagulation: practical advice

Take Eliquis at the same times each day (for example, 8 am and 8 pm) to maintain consistent blood levels.

Use a pill organiser or phone alarm to help remember doses. Always carry your anticoagulant alert card and consider wearing a medical alert bracelet or necklace.

Inform your dentist, pharmacist, optician, podiatrist, and any other healthcare professional that you take an anticoagulant.

Use a soft-bristled toothbrush and an electric shaver to reduce the risk of minor bleeding. Take care with sharp objects and activities that carry a risk of injury.

Avoid excessive alcohol consumption, which increases bleeding risk and may affect liver function.

When to seek urgent medical advice

Seek immediate emergency help by calling 999 or attending A&E if you experience signs of major bleeding (blood in urine, black stools, vomiting blood, heavy nosebleeds, uncontrollable bleeding from wounds), sudden severe headache, confusion, difficulty speaking, sudden weakness or numbness on one side, sudden visual disturbance, sudden breathlessness or chest pain (which may indicate PE), or collapse.

For non-urgent concerns, contact your GP or NHS 111. Report any suspected adverse reactions via the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk .

Sources

• Eliquis 5 mg film-coated tablets, Summary of Product Characteristics (EMC)
• Apixaban, British National Formulary (BNF)
• NICE TA275: Apixaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation
• NICE TA341: Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism
• NICE CG180: Atrial fibrillation: diagnosis and management
• Apixaban, NHS
• MHRA Yellow Card Scheme