Documente Academic
Documente Profesional
Documente Cultură
Date of submission
November 2013
November 2015
Abstract
Key Words
1b, 4
1b
2a
2b
3
4
5
Consultation Process
Target audience
Page 2
Page 3
Appendix 1
Haemorrhage Protocol
Appendix 2
Appendix 3
Page 7
Criteria
Apixaban, dabigatran and rivaroxaban are new oral anticoagulants that are alternatives to
coumarins (e.g. warfarin) in selected groups of patients for certain indications. This guideline is
for patients receiving apixaban (Eliquis) requiring an invasive procedure, emergency surgery or
treatment for haemorrhage. For patients on rivaroxaban (Xarelto) or dabigatran (Pradaxa)
see alternative guidelines on the intranet .
Background
Apixaban (Eliquis) is a direct factor Xa inhibitor licensed to prevent stroke and systemic
embolism in adult patients with nonvalvular atrial fibrillation. It is used in some patients unable to
take warfarin.
Further information can be found on the APC website www.nottsapc.nhs.uk and the
Nottinghamshire Joint Formulary.
This guideline outlines the steps to be taken in patients who are taking apixaban and require an
invasive procedure or who have bleeding complications.
Measurement of anti-coagulation effect of apixaban
Apixaban does not routinely require monitoring of therapeutic response (unlike warfarin).
However, if a patient has an episode of bleeding or requires an invasive procedure, measurement
of an anticoagulant effect may be advantageous.
A specific anti Xa assay can be used to measure the anticoagulant effect of apixaban,
only after discussion with a haematologist.
N.B. Standard coagulation screening tests cannot assess the degree of anticoagulation for
patients taking apixaban. If a patient is known to be taking apixaban, it should NOT be
assumed that haemostasis is normal even if the coagulation screening tests return normal
results. Bleeding patients, or patients requiring interventional procedures must always be
discussed with a haematologist.
Appendix 3 shows the effect of all the new oral anticoagulants on clotting screens
Invasive procedures and elective surgical interventions
Stop apixaban at least 24 hours before intervention (48 hours if moderate-high risk of bleeding).
The bleeding risk for the procedure needs to be assessed by the clinician performing the
procedure. The relevant bleeding risk vs thrombotic risk (with cessation of anticoagulation) needs
to be assessed and discussed with the patient by the clinician performing the procedure. If
procedure cannot be delayed until at least 24 hours post dose, the increased risk of bleeding
should be assessed against the urgency of the intervention.
2
Apixaban should be re-started post procedure when risk of bleeding is judged to be low.
If Xa
RAISED
If Xa
NORMAL
Contact Haematologist
If
Xa RAISED
If Xa NORMAL
Minor Bleed
Mechanical
compression
Delay next dose of
apixaban or
discontinue
Major Bleed
Continues
to bleed
Appendix 3
Effect of the new oral anticoagulants on coagulation screens
Apixaban, dabigatran and rivaroxaban are new oral anticoagulants that
are alternatives to coumarins (e.g. warfarin) in selected groups of patients for certain indications. All these drugs accumulate in renal impairment. A standard clotting screen has not been validated for assessing
the degree of anticoagulation in a patient taking these agents and
should not be used for this purpose. Consult haematology for advice.
Parameter Apixaban
(Eliquis)
Dabigatran
(Pradaxa)
Rivaroxaban
(Xarelto)
Prolonged (in
linear fashion if
neoplastin used as
reagent)
Prolonged
(1.5-1.8 times
control)
PT
Prolonged
No effect
APTT
Prolonged
TT
No effect
Prolonged
(1.4-1.8 times
control) greatly
prolonged if
supratherapeutic
levels
Prolonged
Drug
Activity
Use anti Xa
assay
Platelet
count
No effect
Use Haemoclot
Use anti Xa assay
thrombin inhibitor
assay or ECT
No effect
No effect
D-dimer
Suppressed
levels
Suppressed
levels
Suppressed
levels
Fibrinogen
No effect
No effect
No effect
2.
Responsible Manager
Owen Bennett (Clinical Quality, Risk and Safety Manager)
3.
4.
5.
6.
7.
8.
9.
Equality Group
Assessment of Impact
Age
No Impact Identified
Gender
No Impact Identified
Race
No Impact Identified
Sexual Orientation
No Impact Identified
Religion or belief
Disability
No Impact Identified
No Impact Identified
Working Patterns
No Impact Identified
Social Deprivation
No Impact Identified