This risk minimisation material has been developed for Eliquis for all indications. Please ensure that you are familiar with this material as it contains important safety information. In particular, it is aimed at increasing awareness about the potential risk of bleeding during treatment with Eliquis and providing guidance on how to manage that risk.
- 1. Name of the medicinal product
- 2. Qualitative and quantitative composition
- 3. Pharmaceutical form
- 4. Clinical particulars
- 4.1 Therapeutic indications
- 4.2 Posology and method of administration
- 4.3 Contraindications
- 4.4 Special warnings and precautions for use
- 4.5 Interaction with other medicinal products and other forms of interaction
- 4.6 Fertility, pregnancy and lactation
- 4.7 Effects on ability to drive and use machines
- 4.8 Undesirable effects
- 4.9 Overdose
- 5. Pharmacological properties
- 5.1 Pharmacodynamic properties
- 5.2 Pharmacokinetic properties
- 5.3 Preclinical safety data
- 6. Pharmaceutical particulars
- 6.1 List of excipients
- 6.2 Incompatibilities
- 6.3 Shelf life
- 6.4 Special precautions for storage
- 6.5 Nature and contents of container
- 6.6 Special precautions for disposal and other handling
- 7. Marketing authorisation holder
- 8. Marketing authorisation number(s)
- 9. Date of first authorisation/renewal of the authorisation
- 10. Date of revision of the text
This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions. See section 4.8 for how to report adverse reactions.
Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF)The recommended dose of Eliquis is 5 mg taken orally twice daily.
Dose reductionThe recommended dose of Eliquis is 2.5 mg taken orally twice daily in patients with NVAF and at least two of the following characteristics: age ≥ 80 years, body weight ≤ 60 kg, or serum creatinine ≥ 1.5 mg/dL (133 micromole/L).Therapy should be continued long term.
Treatment of DVT, treatment of PE and prevention of recurrent DVT and PE (VTEt)The recommended dose of Eliquis for the treatment of acute DVT and treatment of PE is 10 mg taken orally twice daily for the first 7 days followed by 5 mg taken orally twice daily. As per available medical guidelines, short duration of treatment (at least 3 months) should be based on transient risk factors (e.g. recent surgery, trauma, immobilisation).The recommended dose of Eliquis for the prevention of recurrent DVT and PE is 2.5 mg taken orally twice daily. When prevention of recurrent DVT and PE is indicated, the 2.5 mg twice daily dose should be initiated following completion of 6 months of treatment with Eliquis 5 mg twice daily or with another anticoagulant, as indicated in Table 1 below (see also section 5.1)Table 1:
|Dosing schedule||Maximum daily dose|
|Treatment of DVT or PE||10 mg twice daily for the first 7 days||20 mg|
|followed by 5 mg twice daily||10 mg|
|Prevention of recurrent DVT and/or PE following completion of 6 months of treatment for DVT or PE||2.5 mg twice daily||5 mg|
Missed DoseIf a dose is missed, the patient should take Eliquis immediately and then continue with twice daily intake as before.
SwitchingSwitching treatment from parenteral anticoagulants to Eliquis (and vice versa) can be done at the next scheduled dose (see section 4.5). These agents should not be administered simultaneously.
Switching from Vitamin K antagonist (VKA) therapy to EliquisWhen converting patients from Vitamin K antagonist (VKA) therapy to Eliquis, discontinue warfarin or other VKA therapy and start Eliquis when the international normalized ratio (INR) is < 2.0.
Switching from Eliquis to VKA therapyWhen converting patients from Eliquis to VKA therapy, continue administration of Eliquis for at least 2 days after beginning VKA therapy. After 2 days of coadministration of Eliquis with VKA therapy, obtain an INR prior to the next scheduled dose of Eliquis. Continue coadministration of Eliquis and VKA therapy until the INR is ≥ 2.0.
Patients with renal impairmentNo dose adjustment is necessary in patients with mild or moderate renal impairment (see section 5.2).In patients with severe renal impairment (creatinine clearance 15-29 mL/min) the following recommendations apply (see sections 4.4 and 5.2):- for the treatment of DVT, treatment of PE and prevention of recurrent DVT and PE (VTEt) apixaban is to be used with caution;- for the prevention of stroke and systemic embolism in patients with NVAF, patients should receive the lower dose of apixaban 2.5 mg twice daily.Patients with serum creatinine ≥ 1.5 mg/dL (133 micromole/L) associated with age ≥ 80 years or body weight ≤ 60 kg should also receive the lower dose of apixaban 2.5 mg twice daily;In patients with creatinine clearance < 15 mL/min, or in patients undergoing dialysis, there is no clinical experience therefore apixaban is not recommended (see sections 4.4 and 5.2).Patients with hepatic impairmentEliquis is contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk (see section 4.3).It is not recommended in patients with severe hepatic impairment (see sections 4.4. and 5.2).It should be used with caution in patients with mild or moderate hepatic impairment (Child Pugh A or B). No dose adjustment is required in patients with mild or moderate hepatic impairment (see sections 4.4 and 5.2).Patients with elevated liver enzymes (ALT/AST >2 x ULN) or total bilirubin ≥1.5 x ULN were excluded in clinical trials. Therefore Eliquis should be used with caution in this population (see sections 4.4 and 5.2). Prior to initiating Eliquis, liver function testing should be performed.
Body weightVTEt - No dose adjustment required (see sections 4.4 and 5.2).NVAF - No dose adjustment required, unless criteria for dose reduction are met (see Dose reduction at the beginning of section 4.2).
GenderNo dose adjustment required (see section 5.2).
ElderlyVTEt - No dose adjustment required (see sections 4.4 and 5.2).NVAF - No dose adjustment required, unless criteria for dose reduction are met (see Dose reduction at the beginning of section 4.2).
Cardioversion (NVAF)Patients can stay on apixaban while being cardioverted.
Paediatric populationThe safety and efficacy of Eliquis in children and adolescents below age 18 have not been established. No data are available.
Method of administrationOral use.Eliquis should be swallowed with water, with or without food.
Haemorrhage riskAs with other anticoagulants, patients taking Eliquis are to be carefully observed for signs of bleeding. It is recommended to be used with caution in conditions with increased risk of haemorrhage. Eliquis administration should be discontinued if severe haemorrhage occurs (see sections 4.8 and 4.9).Although treatment with apixaban does not require routine monitoring of exposure, a calibrated quantitative anti-Factor Xa assay may be useful in exceptional situations where knowledge of apixaban exposure may help to inform clinical decisions, e.g., overdose and emergency surgery (see section 5.1).
Interaction with other medicinal products affecting haemostasisDue to an increased bleeding risk, concomitant treatment with any other anticoagulants is contraindicated (see section 4.3). The concomitant use of Eliquis with antiplatelet agents increases the risk of bleeding (see section 4.5).Care is to be taken if patients are treated concomitantly with non-steroidal anti-inflammatory drugs (NSAIDs), including acetylsalicylic acid.Following surgery, other platelet aggregation inhibitors are not recommended concomitantly with Eliquis (see section 4.5).In patients with atrial fibrillation and conditions that warrant mono or dual antiplatelet therapy, a careful assessment of the potential benefits against the potential risks should be made before combining this therapy with Eliquis. In a clinical trial of patients with atrial fibrillation, concomitant use of ASA increased the major bleeding risk on apixaban from 1.8% per year to 3.4% per year and increased the bleeding risk on warfarin from 2.7% per year to 4.6% per year. In this clinical trial, there was limited (2.1%) use of concomitant dual antiplatelet therapy.In a clinical trial of high-risk post acute coronary syndrome patients, characterized by multiple cardiac and non-cardiac comorbidities, who received ASA or the combination of ASA and clopidogrel, a significant increase in risk of ISTH (International Society on Thrombosis and Haemostasis) major bleeding was reported for apixaban (5.13% per year) compared to placebo (2.04% per year).
Use of Thrombolytic agents for the treatment of acute ischemic strokeThere is very limited experience with the use of thrombolytic agents for the treatment of acute ischemic stroke in patients administered apixaban.
Patients with prosthetic heart valvesSafety and efficacy of Eliquis have not been studied in patients with prosthetic heart valves, with or without atrial fibrillation. Therefore, the use of Eliquis is not recommended in this setting.
Surgery and invasive proceduresEliquis should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of bleeding. This includes interventions for which the probability of clinically significant bleeding cannot be excluded or for which the risk of bleeding would be unacceptable. Eliquis should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding. This includes interventions for which any bleeding that occurs is expected to be minimal, non-critical in its location or easily controlled. If surgery or invasive procedures cannot be delayed, appropriate caution should be exercised, taking into consideration an increased risk of bleeding. This risk of bleeding should be weighed against the urgency of intervention. Apixaban should be restarted after the invasive procedure or surgical intervention as soon as possible provided the clinical situation allows and adequate haemostasis has been established (for cardioversion see section 4.2).
Temporary discontinuationDiscontinuing anticoagulants, including Eliquis, for active bleeding, elective surgery, or invasive procedures places patients at an increased risk of thrombosis. Lapses in therapy should be avoided and if anticoagulation with Eliquis must be temporarily discontinued for any reason, therapy should be restarted as soon as possible.
Haemodynamically unstable PE patients or patients who require thrombolysis or pulmonary embolectomyEliquis is not recommended as an alternative to unfractionated heparin in patients with pulmonary embolism who are haemodynamically unstable or may receive thrombolysis or pulmonary embolectomy since the safety and efficacy of apixaban have not been established in these clinical situations.
Patients with active cancerEfficacy and safety of apixaban in the treatment of DVT, treatment of PE and prevention of recurrent DVT and PE (VTEt) in patients with active cancer have not been established.
Renal impairmentLimited clinical data indicate that apixaban plasma concentrations are increased in patients with severe renal impairment (creatinine clearance 15-29 mL/min) which may lead to an increased bleeding risk. For the treatment of DVT, treatment of PE and prevention of recurrent DVT and PE (VTEt), apixaban is to be used with caution in patients with severe renal impairment (creatinine clearance 15-29 mL/min) (see sections 4.2 and 5.2). For the prevention of stroke and systemic embolism in patients with NVAF, patients with severe renal impairment (creatinine clearance 15-29 mL/min), and patients with serum creatinine ≥ 1.5 mg/dL (133 micromole/L) associated with age ≥ 80 years or body weight ≤ 60 kg should receive the lower dose of apixaban 2.5 mg twice daily (see section 4.2);In patients with creatinine clearance < 15 mL/min, or in patients undergoing dialysis, there is no clinical experience therefore apixaban is not recommended (see sections 4.2 and 5.2).
Elderly patientsIncreasing age may increase haemorrhagic risk (see section 5.2).Also, the co-administration of Eliquis with ASA in elderly patients should be used cautiously because of a potentially higher bleeding risk.
Body weightLow body weight (< 60 kg) may increase haemorrhagic risk (see section 5.2).
Hepatic impairmentEliquis is contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk (see section 4.3).It is not recommended in patients with severe hepatic impairment (see section 5.2).It should be used with caution in patients with mild or moderate hepatic impairment (Child Pugh A or B) (see sections 4.2 and 5.2).Patients with elevated liver enzymes ALT/AST > 2 x ULN or total bilirubin ≥ 1.5 x ULN were excluded in clinical trials. Therefore Eliquis should be used cautiously in this population (see section 5.2). Prior to initiating Eliquis, liver function testing should be performed.
Interaction with inhibitors of both cytochrome P450 3A4 (CYP3A4) and P-glycoprotein (P-gp)The use of Eliquis is not recommended in patients receiving concomitant systemic treatment with strong inhibitors of both CYP3A4 and P-gp, such as azole-antimycotics (e.g., ketoconazole, itraconazole, voriconazole and posaconazole) and HIV protease inhibitors (e.g., ritonavir). These medicinal products may increase apixaban exposure by 2-fold (see section 4.5) or greater in the presence of additional factors that increase apixaban exposure (e.g., severe renal impairment).
Interaction with inducers of both CYP3A4 and P-gpThe concomitant use of Eliquis with strong CYP3A4 and P-gp inducers (e.g., rifampicin, phenytoin, carbamazepine, phenobarbital or St. John's Wort) may lead to a ~50% reduction in apixaban exposure. In a clinical study in atrial fibrillation patients, diminished efficacy and a higher risk of bleeding were observed with coadministration of apixaban with strong inducers of both CYP3A4 and P-gp compared with using apixaban alone. In patients receiving concomitant systemic treatment with strong inducers of both CYP3A4 and P-gp the following recommendations apply (see section 4.5):- for the prevention of stroke and systemic embolism in patients with NVAF and for the prevention of recurrent DVT and PE, apixaban should be used with caution; - for the treatment of DVT and treatment of PE, apixaban should not be used since efficacy may be compromised.
Laboratory parametersClotting tests (e.g., PT, INR, and aPTT) are affected as expected by the mechanism of action of apixaban. Changes observed in these clotting tests at the expected therapeutic dose are small and subject to a high degree of variability (see section 5.1).
Information about excipientsEliquis contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.
Inhibitors of CYP3A4 and P-gpCo-administration of apixaban with ketoconazole (400 mg once a day), a strong inhibitor of both CYP3A4 and P-gp, led to a 2-fold increase in mean apixaban AUC and a 1.6-fold increase in mean apixaban Cmax. The use of Eliquis is not recommended in patients receiving concomitant systemic treatment with strong inhibitors of both CYP3A4 and P-gp, such as azole-antimycotics (e.g., ketoconazole, itraconazole, voriconazole and posaconazole) and HIV protease inhibitors (e.g., ritonavir) (see section 4.4).Active substances which are not considered strong inhibitors of both CYP3A4 and P-gp, (eg. diltiazem, naproxen, amiodarone, verapamil, quinidine) are expected to increase apixaban plasma concentration to a lesser extent. Diltiazem (360 mg once a day), for instance, considered a moderate CYP3A4 and a weak P-gp inhibitor, led to a 1.4-fold increase in mean apixaban AUC and a 1.3-fold increase in Cmax. Naproxen (500 mg, single dose) an inhibitor of P-gp but not an inhibitor of CYP3A4, led to a 1.5-fold and 1.6-fold increase in mean apixaban AUC and Cmax, respectively. No dose adjustment for apixaban is required when co-administered with less potent inhibitors of CYP3A4 and/or P-gp.
Inducers of CYP3A4 and P-gpCo-administration of apixaban with rifampicin, a strong inducer of both CYP3A4 and P-gp, led to an approximate 54% and 42% decrease in mean apixaban AUC and Cmax, respectively. The concomitant use of apixaban with other strong CYP3A4 and P-gp inducers (e.g., phenytoin, carbamazepine, phenobarbital or St. John's Wort) may also lead to reduced apixaban plasma concentrations. No dose adjustment for apixaban is required during concomitant therapy with such agents, however in patients receiving concomitant systemic treatment with strong inducers of both CYP3A4 and P-gp apixaban should be used with caution for the prevention of stroke and systemic embolism in patients with NVAF and for the prevention of recurrent DVT and PE. Apixaban is not recommended for the treatment of DVT and PE in patients receiving concomitant systemic treatment with strong inducers of both CYP3A4 and P-gp since efficacy may be compromised (see section 4.4).
Anticoagulants, platelet aggregation inhibitors and NSAIDsDue to an increased bleeding risk, concomitant treatment with any other anticoagulants is contraindicated (see section 4.3). After combined administration of enoxaparin (40 mg single dose) with apixaban (5 mg single dose), an additive effect on anti-Factor Xa activity was observed.Pharmacokinetic or pharmacodynamic interactions were not evident when apixaban was co-administered with ASA 325 mg once a day.Apixaban co-administered with clopidogrel (75 mg once a day) or with the combination of clopidogrel 75 mg and ASA 162 mg once daily, or with prasugrel (60 mg followed by 10 mg once daily) in Phase 1 studies did not show a relevant increase in template bleeding time, or further inhibition of platelet aggregation, compared to administration of the antiplatelet agents without apixaban. Increases in clotting tests (PT, INR, and aPTT) were consistent with the effects of apixaban alone. Naproxen (500 mg), an inhibitor of P-gp, led to a 1.5-fold and 1.6-fold increase in mean apixaban AUC and Cmax, respectively. Corresponding increases in clotting tests were observed for apixaban. No changes were observed in the effect of naproxen on arachidonic acid-induced platelet aggregation and no clinically relevant prolongation of bleeding time was observed after concomitant administration of apixaban and naproxen. Despite these findings, there may be individuals with a more pronounced pharmacodynamic response when antiplatelet agents are co-administered with apixaban. Eliquis should be used with caution when co-administered with NSAIDs (including acetylsalicylic acid) because these medicinal products typically increase the bleeding risk. A significant increase in bleeding risk was reported with the triple combination of apixaban, ASA and clopidogrel in a clinical study in patients with acute coronary syndrome (see section 4.4). Agents associated with serious bleeding are not recommended concomitantly with Eliquis, such as: thrombolytic agents, GPIIb/IIIa receptor antagonists, thienopyridines (e.g., clopidogrel), dipyridamole, dextran and sulfinpyrazone.
Other concomitant therapiesNo clinically significant pharmacokinetic or pharmacodynamic interactions were observed when apixaban was co-administered with atenolol or famotidine. Co-administration of apixaban 10 mg with atenolol 100 mg did not have a clinically relevant effect on the pharmacokinetics of apixaban. Following administration of the two medicinal products together, mean apixaban AUC and Cmax were 15% and 18% lower than when administered alone. The administration of apixaban 10 mg with famotidine 40 mg had no effect on apixaban AUC or Cmax.
Effect of apixaban on other medicinal productsIn vitro apixaban studies showed no inhibitory effect on the activity of CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2D6 or CYP3A4 (IC50 > 45 μM) and weak inhibitory effect on the activity of CYP2C19 (IC50 > 20 μM) at concentrations that are significantly greater than peak plasma concentrations observed in patients. Apixaban did not induce CYP1A2, CYP2B6, CYP3A4/5 at a concentration up to 20 μM. Therefore, apixaban is not expected to alter the metabolic clearance of coadministered drugs that are metabolized by these enzymes. Apixaban is not a significant inhibitor of P-gp.In studies conducted in healthy subjects, as described below, apixaban did not meaningfully alter the pharmacokinetics of digoxin, naproxen, or atenolol.Digoxin: Co-administration of apixaban (20 mg once a day) and digoxin (0.25 mg once a day), a P-gp substrate, did not affect digoxin AUC or Cmax. Therefore, apixaban does not inhibit P-gp mediated substrate transport.Naproxen: Co-administration of single doses of apixaban (10 mg) and naproxen (500 mg), a commonly used NSAID, did not have any effect on the naproxen AUC or Cmax.Atenolol: Co-administration of a single dose of apixaban (10 mg) and atenolol (100 mg), a common beta-blocker, did not alter the pharmacokinetics of atenolol.
Activated CharcoalAdministration of activated charcoal reduces apixaban exposure (see section 4.9).
PregnancyThere are no data from the use of apixaban in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity. Apixaban is not recommended during pregnancy.
Breast-feedingIt is unknown whether apixaban or its metabolites are excreted in human milk. Available data in animals have shown excretion of apixaban in milk. In rat milk, a high milk to maternal plasma ratio (Cmax about 8, AUC about 30) was found, possibly due to active transport into the milk. A risk to newborns and infants cannot be excluded.A decision must be made to either discontinue breast-feeding or to discontinue/abstain from apixaban therapy.
FertilityStudies in animals dosed with apixaban have shown no effect on fertility (see section 5.3).
Summary of the safety profileThe safety of apixaban has been investigated in 4 Phase III clinical studies including more than 15,000 patients: more than 11,000 patients in NVAF studies and more than 4,000 patients in the VTE treatment (VTEt) studies, for an average total exposure of 1.7 years and 221 days respectively (see section 5.1).Common adverse reactions were haemorrhage, contusion, epistaxis, and haematoma (see Table 2 for adverse event profile and frequencies by indication).In the NVAF studies, the overall incidence of adverse reactions related to bleeding with apixaban was 24.3% in the apixaban vs warfarin study and 9.6% in the apixaban vs aspirin study. In the apixaban vs warfarin study the incidence of ISTH major gastrointestinal bleeds (including upper GI, lower GI, and rectal bleeding) with apixaban was 0.76%/year. The incidence of ISTH major intraocular bleeding with apixaban was 0.18%/year.In the VTEt studies, the overall incidence of adverse reactions related to bleeding with apixaban was 15.6% in the apixaban vs enoxaparin/warfarin study and 13.3% in the apixaban vs placebo study (see section 5.1).
Tabulated list of adverse reactionsTable 2 shows the adverse reactions ranked under headings of System Organ Class and frequency using the following convention: very common (≥1/10) common (≥1/100 to < 1/10); uncommon (≥1/1,000 to < 1/100); rare (≥1/10,000 to < 1/1,000); very rare (< 1/10,000); not known (cannot be estimated from the available data) for NVAF and VTEt respectively.Table 2
|System Organ Class||Prevention of stroke and systemic embolism in adult patients with NVAF, with one or more risk factors ( NVAF)||Treatment of DVT and PE, and prevention of recurrent DVT and PE (VTEt)|
|Immune system disorders|
|Hypersensitivity, allergic edema and Anaphylaxis||Uncommon||-|
|Nervous system disorders|
|Eye haemorrhage (including conjunctival haemorrhage)||Common||Uncommon|
|Respiratory, thoracic and mediastinal disorders|
|Respiratory tract haemorrhage||Rare||Rare|
|Haemorrhoidal haemorrhage, mouth haemorrhage||Uncommon||-|
|Rectal haemorrhage, gingival bleeding||Common||Common|
|Skin and subcutaneous tissue disorders|
|Renal and urinary disorders|
|Reproductive system and breast disorders|
|Abnormal vaginal haemorrhage, urogenital haemorrhage||Uncommon||Uncommon|
|General disorders and administration site conditions|
|Application site bleeding||Uncommon||-|
|Occult blood positive||Uncommon||Uncommon|
|Injury, poisoning and procedural complications|
|Traumatic haemorrhage, post procedural haemorrhage, incision site haemorrhage||Uncommon||Uncommon|
Reporting of suspected adverse reactionsReporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.
Mechanism of actionApixaban is a potent, oral, reversible, direct and highly selective active site inhibitor of factor Xa. It does not require antithrombin III for antithrombotic activity. Apixaban inhibits free and clot-bound factor Xa, and prothrombinase activity. Apixaban has no direct effects on platelet aggregation, but indirectly inhibits platelet aggregation induced by thrombin. By inhibiting factor Xa, apixaban prevents thrombin generation and thrombus development. Preclinical studies of apixaban in animal models have demonstrated antithrombotic efficacy in the prevention of arterial and venous thrombosis at doses that preserved haemostasis.
Pharmacodynamic effectsThe pharmacodynamic effects of apixaban are reflective of the mechanism of action (FXa inhibition). As a result of FXa inhibition, apixaban prolongs clotting tests such as prothrombin time (PT), INR and activated partial thromboplastin time (aPTT). Changes observed in these clotting tests at the expected therapeutic dose are small and subject to a high degree of variability. They are not recommended to assess the pharmacodynamic effects of apixaban.Apixaban also demonstrates anti-FXa activity as evident by reduction in Factor Xa enzyme activity in multiple commercial anti-FXa kits, however results differ across kits. Data from clinical trials are only available for the Rotachrom Heparin chromogenic assay. Anti-FXa activity exhibits a close direct linear relationship with apixaban plasma concentration, reaching maximum values at the time of apixaban peak plasma concentrations. The relationship between apixaban plasma concentration and anti-FXa activity is approximately linear over a wide dose range of apixaban.Table 3 below shows the predicted steady state exposure and anti-Factor Xa activity. In nonvalvular atrial fibrillation patients taking apixaban for the prevention of stroke and systemic embolism, the results demonstrate a less than 1.7-fold fluctuation in peak-to-trough levels. In patients taking apixaban for the treatment of DVT and PE or prevention of recurrent DVT and PE, the results demonstrate a less than 2.2-fold fluctuation in peak-to-trough levels.
|Table 3: Predicted Apixaban Steady-state Exposure and Anti-Xa Activity|
|Apix.Cmax (ng/mL)||Apix.Cmin (ng/mL)||Apix. Anti-Xa Activity Max (IU/mL)||Apix. Anti-Xa Activity Min (IU/mL)|
|Median [5th, 95th Percentile]|
|Prevention of stroke and systemic embolism: NVAF|
|2.5 mg BID*||123 [69, 221]||79 [34, 162]||1.8 [1.0, 3.3]||1.2 [0.51, 2.4]|
|5 mg BID||171 [91, 321]||103 [41, 230]||2.6 [1.4, 4.8]||1.5 [0.61, 3.4]|
|Treatment of DVT, treatment of PE and prevention of recurrent DVT and PE (VTEt)|
|2.5 mg BID||67 [30, 153]||32 [11, 90]||1.0 [0.46, 2.5]||0.49 [0.17, 1.4]|
|5 mg BID||132 [59, 302]||63 [22, 177]||2.1 [0.91, 5.2]||1.0 [0.33, 2.9]|
|10 mg BID||251 [111, 572]||120 [41, 335]||4.2 [1.8, 10.8]||1.9 [0.64, 5.8]|
Clinical efficacy and safety
Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF)A total of 23,799 patients were randomised in the clinical program (ARISTOTLE: apixaban versus warfarin, AVERROES: apixaban versus ASA) including 11,927 randomised to apixaban. The program was designed to demonstrate the efficacy and safety of apixaban for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF) and one or more additional risk factors, such as: • prior stroke or transient ischaemic attack (TIA) • age ≥ 75 years • hypertension • diabetes mellitus • symptomatic heart failure (NYHA Class ≥ II)
ARISTOTLE STUDYIn the ARISTOTLE study a total of 18,201 patients were randomized to double-blind treatment with apixaban 5 mg twice daily (or 2.5 mg twice daily in selected patients [4.7%], see section 4.2) or warfarin (target INR range 2.0-3.0), patients were exposed to study drug for a mean of 20 months. The mean age was 69.1 years, the mean CHADS2 score was 2.1, 18.9 % of patients had prior stroke or TIA.In the study, apixaban achieved statistically significant superiority in the primary endpoint of prevention of stroke (haemorrhagic or ischaemic) and systemic embolism (see Table 4) compared with warfarin. Table 4: Efficacy Outcomes in Patients with Atrial Fibrillation in the ARISTOTLE Study
|Apixaban N=9120n (%/yr)||Warfarin N=9081n (%/yr)||Hazard Ratio(95% CI)||p-value|
|Stroke or systemic embolism||212 (1.27)||265 (1.60)||0.79 (0.66, 0.95)||0.0114|
|Ischaemic or unspecified||162 (0.97)||175 (1.05)||0.92 (0.74, 1.13)|
|Haemorrhagic||40 (0.24)||78 (0.47)||0.51 (0.35, 0.75)|
|Systemic embolism||15 (0.09)||17 (0.10)||0.87 (0.44, 1.75)|
|ApixabanN = 9088n (%/year)||WarfarinN = 9052n (%/year)||Hazard Ratio(95% CI)||p-value|
|Major*||327 (2.13)||462 (3.09)||0.69 (0.60, 0.80)||< 0.0001|
|Fatal||10 (0.06)||37 (0.24)|
|Intracranial||52 (0.33)||122 (0.80)|
|Major + CRNM||613 (4.07)||877 (6.01)||0.68 (0.61, 0.75)||< 0.0001|
|All||2356 (18.1)||3060 (25.8)||0.71 (0.68, 0.75)||< 0.0001|
|All-cause death||603 (3.52)||669 (3.94)||0.89 (0.80, 1.00)||0.0465|
|Myocardial infarction||90 (0.53)||102 (0.61)||0.88 (0.66, 1.17)|
AVERROES STUDYIn the AVERROES study a total of 5,598 patients considered to be unsuitable for VKA by the investigators were randomized to treatment with apixaban 5 mg twice daily (or 2.5 mg twice daily in selected patients [6.4%], see section 4.2) or ASA. ASA was given at a once daily dose of 81 mg (64%), 162 (26.9%), 243 (2.1%), or 324 mg (6.6%) at the discretion of the investigator. Patients were exposed to study drug for a mean of 14 months. The mean age was 69.9 years, the mean CHADS2 score was 2.0 and 13.6% of patients had prior stroke or TIA. Common reasons for unsuitability for VKA therapy in the AVERROES study included unable/unlikely to obtain INRs at requested intervals (42.6%), patient refused treatment with VKA (37.4%), CHADS2 score = 1 and physician did not recommend VKA (21.3%), patient could not be relied on to adhere to VKA medication instruction (15.0%), and difficulty/expected difficulty in contacting patient in case of urgent dose change (11.7%). AVERROES was stopped early based on a recommendation by the independent Data Monitoring Committee due to clear evidence of reduction of stroke and systemic embolism with an acceptable safety profile. The overall discontinuation rate due to adverse reactions was 1.5% for apixaban and 1.3% for ASA in the AVERROES study.In the study, apixaban achieved statistically significant superiority in the primary endpoint of prevention of stroke (haemorrhagic, ischaemic or unspecified) or systemic embolism (see Table 6) compared to ASA.Table 6: Key Efficacy Outcomes in Patients with Atrial Fibrillation in the AVERROES Study
|ApixabanN = 2807 n (%/year)||ASA N = 2791n (%/year)||Hazard Ratio(95% CI)||p-value|
|Stroke or systemic embolism*||51 (1.62)||113 (3.63)||0.45 (0.32, 0.62)||< 0.0001|
|Ischaemic or unspecified||43 (1.37)||97 (3.11)||0.44 (0.31, 0.63)|
|Haemorrhagic||6 (0.19)||9 (0.28)||0.67 (0.24, 1.88)|
|Systemic embolism||2 (0.06)||13 (0.41)||0.15 (0.03, 0.68)|
|Stroke, systemic embolism, MI, or vascular death*||132 (4.21)||197 (6.35)||0.66 (0.53, 0.83)||0.003|
|Myocardial infarction||24 (0.76)||28 (0.89)||0.86 (0.50, 1.48)|
|Vascular Death||84 (2.65)||96 (3.03)||0.87 (0.65, 1.17)|
|All-cause death||111 (3.51)||140 (4.42)||0.79 (0.62, 1.02)||0.068|
|ApixabanN = 2798n(%/year)||ASAN = 2780n (%/year)||Hazard Ratio(95%CI)||p-value|
|Major*||45 (1.41)||29 (0.92)||1.54 (0.96, 2.45)||0.0716|
|Fatal, n||5 (0.16)||5 (0.16)|
|Intracranial, n||11 (0.34)||11 (0.35)|
|Major + CRNM||140 (4.46)||101 (3.24)||1.38 (1.07, 1.78)||0.0144|
|All||325 (10.85)||250 (8.32)||1.30 (1.10, 1.53)||0.0017|
Treatment of DVT, treatment of PE and prevention of recurrent DVT and PE (VTEt)The clinical program (AMPLIFY: apixaban versus enoxaparin/warfarin, AMPLIFY-EXT: apixaban versus placebo) was designed to demonstrate the efficacy and safety of apixaban for the treatment of DVT and/or PE (AMPLIFY), and extended therapy for the prevention of recurrent DVT and/or PE following 6 to 12 months of anticoagulant treatment for DVT and/or PE (AMPLIFY-EXT). Both studies were randomized, parallel-group, double-blind, multinational trials in patients with symptomatic proximal DVT or symptomatic PE. All the key safety and efficacy endpoints were adjudicated by an independent blinded committee.
AMPLIFY STUDYIn the AMPLIFY study a total of 5,395 patients were randomized to treatment with apixaban 10 mg twice daily orally for 7 days followed by apixaban 5 mg twice daily orally for 6 months, or enoxaparin 1 mg/kg twice daily subcutaneously for at least 5 days (until INR≥ 2) and warfarin (target INR range 2.0-3.0) orally for 6 months. The mean age was 56.9 years and 89.8% of randomised patients had unprovoked VTE events.For patients randomized to warfarin, the mean percentage of time in therapeutic range (INR 2.0-3.0) was 60.9. Apixaban showed a reduction in recurrent symptomatic VTE or VTE- related death across the different levels of center TTR; within the highest quartile of TTR according to center, the relative risk for apixaban vs enoxaparin/warfarin was 0.79 (95% CI, 0.39, 1.61).In the study, apixaban was shown to be non-inferior to enoxaparin/warfarin in the combined primary endpoint of adjudicated recurrent symptomatic VTE (nonfatal DVT or nonfatal PE) or VTE-related death (see Table 8).Table 8: Efficacy Results in the AMPLIFY Study
|ApixabanN=2609n (%)||Enoxaparin/WarfarinN=2635n (%)||Relative Risk(95% CI)|
|VTE or VTE-related death||59 (2.3)||71 (2.7)||0.84 (0.60, 1.18)*|
|DVT||20 (0.7)||33 (1.2)|
|PE||27 (1.0)||23 (0.9)|
|VTE-related death||12 (0.4)||15 (0.6)|
|VTE or all-cause death||84 (3.2)||104 (4.0)||0.82 (0.61, 1.08)|
|VTE or CV-related death||61 (2.3)||77 (2.9)||0.80 (0.57, 1.11)|
|VTE, VTE-related death, or major bleeding||73 (2.8)||118 (4.5)||0.62 (0.47, 0.83)|
|ApixabanN=2676n (%)||Enoxaparin/WarfarinN=2689n (%)||Relative Risk(95% CI)|
|Major||15 (0.6)||49 (1.8)||0.31 (0.17, 0.55)|
|Major + CRNM||115 (4.3)||261 (9.7)||0.44 (0.36, 0.55)|
|Minor||313 (11.7)||505 (18.8)||0.62 (0.54, 0.70)|
|All||402 (15.0)||676 (25.1)||0.59 (0.53, 0.66)|
AMPLIFY-EXT STUDYIn the AMPLIFY-EXT study a total of 2,482 patients were randomized to treatment with apixaban 2.5 mg twice daily orally, apixaban 5 mg twice daily orally, or placebo for 12 months after completing 6 to 12 months of initial anticoagulant treatment. Of these, 836 patients (33.7%) participated in the AMPLIFY study prior to enrollment in the AMPLIFY-EXT study. The mean age was 56.7 years and 91.7% of randomised patients had unprovoked VTE events.In the study, both doses of apixaban were statistically superior to placebo in the primary endpoint of symptomatic, recurrent VTE (nonfatal DVT or nonfatal PE) or all-cause death (see Table 10).Table 10: Efficacy Results in the AMPLIFY-EXT Study
|Apixaban||Apixaban||Placebo||Relative Risk (95% CI)|
|2.5 mg(N=840)||5.0 mg(N=813)||(N=829)||Apix 2.5 mgvs. Placebo||Apix 5.0 mgvs. Placebo|
|Recurrent VTE or all-cause death||19 (2.3)||14 (1.7)||77 (9.3)||0.24 (0.15, 0.40)¥||0.19 (0.11, 0.33)¥|
|DVT*||6 (0.7)||7 (0.9)||53 (6.4)|
|PE*||7 (0.8)||4 (0.5)||13 (1.6)|
|All-cause death||6 (0.7)||3 (0.4)||11 (1.3)|
|Recurrent VTE or VTE-related death||14 (1.7)||14 (1.7)||73 (8.8)||0.19 (0.11, 0.33)||0.20 (0.11, 0.34)|
|Recurrent VTE or CV-related death||14 (1.7)||14 (1.7)||76 (9.2)||0.18 (0.10, 0.32)||0.19 (0.11, 0.33)|
|Nonfatal DVT||6 (0.7)||8 (1.0)||53 (6.4)||0.11 (0.05, 0.26)||0.15 (0.07, 0.32)|
|Nonfatal PE||8 (1.0)||4 (0.5)||15 (1.8)||0.51 (0.22, 1.21)||0.27 (0.09, 0.80)|
|VTE-related death||2 (0.2)||3 (0.4)||7 (0.8)||0.28 (0.06, 1.37)||0.45 (0.12, 1.71)|
|Apixaban||Apixaban||Placebo||Relative Risk (95% CI)|
|2.5 mg(N=840)||5.0 mg(N=813)||(N=829)||Apix 2.5 mgvs. Placebo||Apix 5.0 mgvs. Placebo|
|Major||2 (0.2)||1 (0.1)||4 (0.5)||0.49 (0.09, 2.64)||0.25 (0.03, 2.24)|
|Major + CRNM||27 (3.2)||35 (4.3)||22 (2.7)||1.20 (0.69, 2.10)||1.62 (0.96, 2.73)|
|Minor||75 (8.9)||98 (12.1)||58 (7.0)||1.26 (0.91, 1.75)||1.70 (1.25, 2.31)|
|All||94 (11.2)||121 (14.9)||74 (9.0)||1.24 (0.93, 1.65)||1.65 (1.26, 2.16)|
Paediatric populationThe European Medicines Agency has deferred the obligation to submit the results of studies with Eliquis in one or more subsets of the paediatric population in venous and arterial embolism and thrombosis (see section 4.2 for information on paediatric use).
AbsorptionThe absolute bioavailability of apixaban is approximately 50% for doses up to 10 mg. Apixaban is rapidly absorbed with maximum concentrations (Cmax) appearing 3 to 4 hours after tablet intake. Intake with food does not affect apixaban AUC or Cmax at the 10 mg dose. Apixaban can be taken with or without food.Apixaban demonstrates linear pharmacokinetics with dose proportional increases in exposure for oral doses up to 10 mg. At doses ≥ 25 mg apixaban displays dissolution limited absorption with decreased bioavailability. Apixaban exposure parameters exhibit low to moderate variability reflected by a within-subject and inter-subject variability of ~20% CV and ~30% CV, respectively.
DistributionPlasma protein binding in humans is approximately 87%. The volume of distribution (Vss) is approximately 21 litres.
Biotransformation and eliminationApixaban has multiple routes of elimination. Of the administered apixaban dose in humans, approximately 25% was recovered as metabolites, with the majority recovered in faeces. Renal excretion of apixaban accounts for approximately 27% of total clearance. Additional contributions from biliary and direct intestinal excretion were observed in clinical and nonclinical studies, respectively.Apixaban has a total clearance of about 3.3 l/h and a half-life of approximately 12 hours.O-demethylation and hydroxylation at the 3-oxopiperidinyl moiety are the major sites of biotransformation. Apixaban is metabolized mainly via CYP3A4/5 with minor contributions from CYP1A2, 2C8, 2C9, 2C19, and 2J2. Unchanged apixaban is the major drug-related component in human plasma with no active circulating metabolites present. Apixaban is a substrate of transport proteins, P-gp and breast cancer resistance protein (BCRP).
Renal impairmentThere was no impact of impaired renal function on peak concentration of apixaban. There was an increase in apixaban exposure correlated to decrease in renal function, as assessed via measured creatinine clearance. In individuals with mild (creatinine clearance 51-80 mL/min), moderate (creatinine clearance 30-50 mL/min) and severe (creatinine clearance 15-29 mL/min) renal impairment, apixaban plasma concentrations (AUC) were increased 16, 29, and 44% respectively, compared to individuals with normal creatinine clearance. Renal impairment had no evident effect on the relationship between apixaban plasma concentration and anti-FXa activity.In subjects with end-stage renal disease (ESRD), the AUC of apixaban was increased by 36% when a single dose of apixaban 5 mg was administered immediately after haemodialysis, compared to that seen in subjects with normal renal function. Haemodialysis, started two hours after administration of a single dose of apixaban 5 mg, decreased apixaban AUC by 14% in these ESRD subjects, corresponding to an apixaban dialysis clearance of 18 mL/min. Therefore, haemodialysis is unlikely to be an effective means of managing apixaban overdose.
Hepatic impairmentIn a study comparing 8 subjects with mild hepatic impairment, Child-Pugh A score 5 (n = 6) and score 6 (n = 2), and 8 subjects with moderate hepatic impairment (Child-Pugh B score 7 (n = 6) and score 8 (n = 2), to 16 healthy control subjects, the single-dose pharmacokinetics and pharmacodynamics of apixaban 5 mg were not altered in subjects with hepatic impairment. Changes in anti-Factor Xa activity and INR were comparable between subjects with mild to moderate hepatic impairment and healthy subjects.
ElderlyElderly patients (above 65 years) exhibited higher plasma concentrations than younger patients, with mean AUC values being approximately 32% higher and no difference in Cmax.
GenderExposure to apixaban was approximately 18% higher in females than in males.
Ethnic origin and raceThe results across phase 1 studies showed no discernible difference in apixaban pharmacokinetics between White/Caucasian, Asian and Black/African American subjects. Findings from a population pharmacokinetic analysis in patients who received apixaban were generally consistent with the phase 1 results.
Body weightCompared to apixaban exposure in subjects with body weight of 65 to 85 kg, body weight > 120 kg was associated with approximately 30% lower exposure and body weight < 50 kg was associated with approximately 30% higher exposure.
Pharmacokinetic/pharmacodynamic relationshipThe pharmacokinetic /pharmacodynamic (PK/PD) relationship between apixaban plasma concentration and several PD endpoints (anti-FXa activity, INR, PT, aPTT) has been evaluated after administration of a wide range of doses (0.5 50 mg). The relationship between apixaban plasma concentration and anti-factor Xa activity was best described by a linear model. The PK/PD relationship observed in patients was consistent with that established in healthy subjects.
Tablet core:Anhydrous lactose Microcrystalline cellulose (E460)Croscarmellose sodiumSodium laurilsulfateMagnesium stearate (E470b)
Film coat:Lactose monohydrateHypromellose (E464)Titanium dioxide (E171)Triacetin (E1518)Iron oxide red (E172)
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