Apixaban Switch Protocol

NHS Borders clinical guidelines
NHS Borders

Objectives

To support the implementation of the Apixaban switch protocol following an advanced patient assessment.

Scope

Reason

NHS Borders are reviewing all patients currently receiving a Direct Oral Anticoagulant (DOAC).   Apixaban is now the preferred choice of DOAC within NHS Borders.  

All DOACs are licensed and approved by the Scottish Medicines Consortium for stroke prevention in Non Valvular – Atrial Fibrillation (NV-AF) and treatment and prevention of DVT/PE.   They are similarly effective however apixaban is the most cost effective. 

This formulary decision is based on current evidence and supported locally by expert clinicians. 

All newly diagnosed NV-AF, DVT and PE patients should be started on apixaban as first choice where treatment with a DOAC is appropriate.  Existing patients already on a DOAC for NV-AF or long term prophylaxis of DVT/PE are to be reviewed and considered for a switch to apixaban.

Note- the difference between edoxaban and apixaban is not marked and where patients would prefer a once daily drug, or where compliance is an issue switching the patients from edoxaban is not really justified.

Preparation and Planning

Implementation of the switch protocol is as follows:

  • Protocol is to be discussed with all GPs in the practice to ensure there is agreement to proceed.
  • Computer search of all patients according to the inclusion criteria.
  • Review of patient's medical notes and repeat prescribing records.
  • Data collection sheets to be completed and passed to relevant GPCP.
  • Community pharmacists are to be informed of the switch so as to review existing stock.

How to Switch Patients to Apixaban

Weight and bloods should be confirmed within the preceding 6 months.  If eGFR is not available updated U&E’s should be taken in accordance with practice protocol.  Weight must also be established – this could be provided by the patient by measuring at home.

Patients should be advised to use up their current supply of DOAC before they change to apixaban.  They should switch to apixaban the day after using up their existing supplies. 

DOAC

 Apixaban
Baseline checks Renal function: serum creatinine (Cr), full blood count (FBC), liver function tests (LFTs) and actual bodyweight
Dosing in Non-valvular AF (NV-AF) (lifelong unless risk:benefit of anticoagulation therapy changes)

Prescribe Apixaban 5mg twice daily

Reduce dose to 2.5mg twice daily if at least two of the following characteristics: age ≥ 80 years, body weight ≤ 60 kg, or serum creatinine ≥ 133 micromol/l or if exclusive criteria of CrCl 15 - 29 ml/min.
Dosing in patients with DVT / PE

Initially Apixaban 10mg TWICE daily for 7 days then maintenance 5mg twice daily (use with caution if CrCl <30ml/min).

Check intended duration of therapy.

For long term prevention or recurrence 2.5mg twice daily

(after 6 months’ treatment dose).
Duration of therapy for DVT/PE

For a provoked DVT/PE: 3 months treatment if provoking factors have been addressed. For unprovoked DVT/PE or recurrent DVT/PE: At least 6 months treatment dose followed by prophylaxis dosing as indicated/advised.
Contraindications

CrCl <15ml/m, hepatic disease associated with coagulopathy and clinically relevant bleeding risk.

Interactions see BNF/SPC for full list

BNF: British National Formulary | BNF Publications (pharmaceuticalpress.com)   

SPC: Home - electronic medicines compendium (emc)

Ketoconazole, itraconazole, voriconazole, posaconazole, ritonavir - not recommended (See SPC for full details) Rifampicin, phenytoin, carbamazepine, phenobarbital, St. John's Wort – use with caution in AF or VTE prevention. Do not use apixaban with patients on strong enzyme inducers for acute VTE treatment.

 

Inclusion & Exclusion Criteria

Inclusion Criteria:

  • All patients currently prescribed a DOAC for the prophylaxis of stroke and systemic embolism in non valvular atrial fibrillation (NV-AF)
  • All patients prescribed a DOAC for long term prophylaxis of DVT/PE
  • DOACs included in the search: edoxaban, dabigatran, rivaroxaban. 

Exclusion Criteria:

  • For patients with Creatinine Clearance (CrCl) <15ml/min – DOACs are not suitable and patients should receive warfarin.
  • Metallic heart valves: warfarin is recommended for these patients.
  • Antiphospholipid syndrome.
  • Patients taking edoxaban, dabigatran or rivaroxaban for prophylaxis of venous thromboembolism. following knee or hip replacement surgery.
  • Existing patients undergoing cardioversion.
  • Active bleeding or significant risk of.
  • not suitable due to compliance concerns.
  • Intolerance or treatment failure with apixaban previously.

Interactions

Other medications/interactions

The risk of bleeding is increased if apixaban is used in combination with anti-platelets.  The combination can be clinically appropriate in certain circumstances but should only be done on the advice of a specialist.  There should also be a clear treatment plan stating the intended duration of treatment.

Contraindications

Liver function

All DOACs are contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk and are not recommended in patients with severe hepatic impairment.

Apixaban should be used with caution in patients with mild to moderate hepatic impairment.

Liver function tests are recommended prior to treatment for those patients with elevated liver enzymes (ALT/AST>2xULN) or total bilirubin ≥1.5 x ULN.

Further Information

Compliance devices

There are no known issues of apixaban in compliance devices.

Patient Letter

Apixaban Switch Protocol Appendix 1 Patient Letter

 

Editorial Information

Last reviewed: 30/11/2025

Next review date: 30/11/2028

Author(s): Morrison, R.

Version: 1.0

Co-Author(s): Neary, P, MacKay, T, Campbell, R, McKaig, R.

Approved By: NHS Borders Anticoagulation Committee

Reviewer name(s): Morrison, R.

References

Apixaban for the treatment and secondary prevention of deep vein thrombosis and or pulmonary embolism (June 2015) NICE TA341 https://www.nice.org.uk/guidance/ta341

Apixaban for preventing stroke and systemic embolism in non-valvular atrial fibrillation (July 2021) NICE TA275  https://www.nice.org.uk/guidance/ta275

BNF https://bnf.nice.org.uk/

Summary of Product Characteristics Available at:  https://www.medicines.org.uk/emc/product/2878/smpc#about-medicine

Creatinine Clearance Calculator:                                                            https://www.mdcalc.com/calc/43/creatinine-clearance-cockcroft-gault-equation

NICE Clinical Knowledge Summaries: Anticoagulation – oral       https://cks.nice.org.uk/topics/anticoagulation-oral

Adapted from NHS Dumfries and Galloway protocol.