Template letter to Primary Care from Specialist following initiation of apixaban
for stroke prevention in AF
Dear Dr
Your patient has today been started on apixaban to prevent stroke associated with nonvalvular atrial fibrillation.
The decision to do so instead of using warfarin has been made on the basis of:
predicted to be difficult to maintain the therapeutic range on warfarin because of the need for
variable interacting medications e.g. recurrent antibiotics
with known excess use of ethanol (but patient is judged as likely to comply with treatment)
domicillary testing would be required with warfarin
a very high stroke risk e.g. CHADS2 score > 3, and rapid anticoagulation is considered clinically
necessary, and with no absolute or relative contraindication to apixaban.
A previous hypersensitivity or serious side effect to warfarin which has lead to discontinuation in
the past
Previous demonstrated resistance to warfarin
TTR <65% after >3months taking warfarin, despite good compliance
History of stroke or TIA whilst taking warfarin despite good compliance
History of significant bleeding on warfarin (evidence supports use of apixaban for this group of
patients)
CHADS2 =
% annual stroke
HASBLED =
% annual bleed risk
risk
CrCl
Hb
Platelets
Your patient has been prescribed:
Apixaban 5mg bd
Apixaban 2.5mg bd
Your patient has:

Been counselled about the safe use of apixaban



Been supplied with the attached frequently asked questions sheet
Signed the attached patient agreement (discretionary document) Yes
Been supplied with an alert card (produced by the manufacturer)
/ No
The following monitoring is recommended for patients on apixaban

For patients with CrCl >50 ml/min: check renal function 12 monthly

For patients with CrCl 30-49ml/min: check renal function 6 monthly
(More frequent checks on renal function may be necessary in patients >80years old, weight <60kg or in those
where a decline in renal function is suspected).

FBC
12 monthly, to check for signs of bleeding
Annual review

History of any stroke/ TIA or bleeding in the last year

Recheck HASBLED and review renal function and FBC
If at any point the CrCl drops below 15ml/min, stop apixaban and recheck HASBLED score. Change to
aspirin if the risks of anticoagulation are considered to outweigh the benefits. If anticoagulation is still
indicated, swap to warfarin and/or refer to specialist.
If HASBLED rises, or bleeding events or a fall in Hb occur, consider whether anticoagulation is still
indicated and/or consider referral to a specialist.
APIXABAN KEY POINTS for clinicians

It does not require blood tests to monitor anticoagulant effect (INR monitoring)

Regular blood tests are needed to monitor kidney function and look for signs
of bleeding

It must be stopped if kidney function declines so that the CrCl <15ml/min

In patients with severe liver disease associated with clotting problems and
clinically significant bleeding risk, including those with cirrhosis, apixaban
should not be prescribed

Apixaban levels drop by half in approximately 12 hours. Taking the tablets on
a regular basis is therefore very important, and protection from stroke will be
lost if only one dose is missed (the effect of warfarin lasts longer).

In the event of surgery or procedures, apixaban should be stopped 24-48
hours prior to the intervention depending on the bleeding risk of the procedure.
See product SPC for details:
http://www.medicines.org.uk/EMC/medicine/27220/SPC/Eliquis+5+mg+filmcoated+tablets/

Apixaban should not be used with the following drugs because of interactions:
Ketoconazole, itraconazole, voriconazole and posaconazole and HIV
protease inhibitors (e.g., ritonavir).
Caution recommended for concomitant use with strong CYP3A4
rifampicin, phenytoin, carbamazepine, phenobarbital or St. John's
Wort).

Apixaban prolongs clotting tests such as prothrombin time (PT), INR and
activated partial thromboplastin time (aPTT) but these are not a measure of
degree of anticoagulation
 There is no established method to reverse the effect of apixaban. In the event
of suspected overdose, activated charcoal should be administered within 2 hours
of ingestion.
For further information or advice please contact
, the local Trust contact who
will be able to answer any further questions you may have.
Signature of specialist