Whilst apixaban is suitable in most cases of VTE, there are certain instances where it should be used with caution or avoided altogether. Please note that apixaban and other DOACs must not be used for anticoagulation of people with mechanical heart valves.
People who are allergic to or intolerant of apixaban will require an alternative anticoagulant - edoxaban may be a reasonable choice in this setting. Where treatment with apixaban is ineffective, an alternative anticoagulant will be needed. In the first instance, LMWH is usually the most appropriate choice whilst reasons for treatment failure are clarified. The following are also reasons to consider alternative anticoagulants to apixaban.
Renal impairment
Apixaban 5mg twice daily should be used with caution in people with a calculated CrCl <30 ml/min. If the CrCl is <15 ml/min, use of apixaban at any dose would only be appropriate under specialist guidance from renal medicine or haematology. Where calculated CrCl is unavailable, eGFR results may be used instead.
Alternative anticoagulants in this setting are LMWH (at doses appropriate for renal function and with LMWH assay monitoring), and VKAs such as warfarin.
If people are listed on the deceased donor transplant list, the anticoagulant of choice in NHS Borders is warfarin, owing to its reversibility.
Severe hepatic impairment
Apixaban is contraindicated in people with advanced liver disease, specifically in those with Child-Pugh C cirrhosis or a history of previous decompensated cirrhosis. Any such use in this setting should be under specialist guidance from hepatology or haematology.
Alternative anticoagulants in this setting include LMWH and, for people with a baseline INR ≤1.3, warfarin and other VKAs.
Antiphospholipid syndrome
Apixaban and other DOACs should not be used in people with antiphospholipid syndrome (APS). Where there is significant suspicion of APS in a patient presenting with an acute VTE, an alternative anticoagulant should be used until it is possible to clarify whether the patient has APS. Only when this is ruled out should a DOAC be used. Rarely, specific patients with APS will be continued on a DOAC by specialist haematologists.
For indications for testing for APS in a patient presenting with an acute VTE, please refer to the Thrombophilia testing guidance in Related Resources within SECTION 1: Introduction
Where APS is suspected and the patient is undergoing testing for this condition in the setting of an acute VTE, LMWH would usually be the appropriate anticoagulant.
In people with established APS who require anticoagulation, warfarin is the anticoagulant of choice, although LMWH may be used instead under specialist guidance in some cases.
Mechanical heart valve
Apixaban (as well as other DOACs) is contraindicated for people with mechanical (metallic) heart valves. These patients should be on warfarin instead - please see SECTION 6 - Vitamin K antagonists, INR ranges and mechanical heart valves for further information (Section 6 is currently being updated and will be available as soon as possible.)
Venous thrombosis at unusual sites
Apixaban is used for treatment of upper limb DVT in NHS Borders.
For CVST, Apixaban is an option for some patients, but others should be treated with LMWH and warfarin. This is covered in neurology department guidance on the topic of CVST.
For splanchnic vein thrombosis, the choice of anticoagulant will depend on the presence of underlying liver disease and conditions such as APS. This should be discussed with haematology.
NHS Borders clinical guidelines
