|Systematic (IUPAC) name|
|Metabolism||CYP3A4, CYP3A5, CYP1A2 and others|
|Biological half-life||9–14 h|
|Excretion||Biliary (75%), renal (25%)|
|CAS Registry Number|
|Molecular mass||459.497 g/mol|
|(what is this?)|
Apixaban (BMS-562247-01, tradename Eliquis) is an anticoagulant for the treatment of venous thromboembolic events. It is a direct factor Xa inhibitor. Apixaban has been available in Europe since May 2012. An FDA decision on apixaban which was expected on June 28, 2012 was initially delayed before final approval on December 28, 2012. On August 21, 2014, Pfizer announced that apixaban was now FDA approved for treatment and secondary prophylaxis of deep vein thrombosis (DVT) and pulmonary embolism (PE). It is being developed in a joint venture by Pfizer and Bristol-Myers Squibb.
Apixaban is indicated for the following:
- To lower the risk of stroke and embolism in patients with nonvalvular atrial fibrillation.
- Deep vein thrombosis (DVT) prophylaxis. DVT's may lead to pulmonary embolism (PE) in knee or hip replacement surgery patients.
- Treatment of both DVT and PE.
- To reduce the risk of recurring DVT and PE after initial therapy.
Apixaban is recommended by the National Institute for Health and Clinical Excellence for the prevention of stroke and systemic embolism in people with non-valvular atrial fibrillation and at least one of the following risk factors: prior stroke or transient ischemic attack, age 75 years or older, diabetes mellitus, or symptomatic heart failure.
Apixaban and other newer anticoagulants (dabigatran and rivaroxaban) appear equally effective as warfarin in preventing non-hemorrhagic stroke in people with atrial fibrillation and are associated with lower risk of intracranial bleeding.
Premature discontinuation of any oral anticoagulant, including apixaban, increases thrombotic event risk for reasons other than pathological bleeding or completion of therapy course. However, this is due to the risk returning to that without anticoagulant therapy and not due to any rebound effect from discontinuation. To reduce this risk, administering another anticoagulant is advised.
Apixaban can increase the risk of bleeding and may cause serious, potentially fatal, bleeding. Concurrent use with drugs affecting hemostasis (e.g. other anticoagulants, heparin, aspirin and other antiplatelet drugs, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and nonsteroidal anti-inflammatory drugs (NSAIDs) can further increase the risk of bleeding.
One concern with the use of apixaban and the other newer anticoagulants is the absence of well-established protocol for reversal of their activity (no antidote is available). This is an important disadvantage relative to warfarin when bleeding complications occur or when people taking the drugs require emergency surgery.
When spinal/epidural anesthesia or puncture is utilized, patients who are being treated with anti-thrombotic agents for the prevention of thromboembolic complications are at risk for developing a hematoma, which can cause long-term or permanent paralysis. The risk of this may be increased by using epidural or intrathecal catheters after a surgical operation or from the concurrent use of medicinal agents that affect hemostasis.
Mechanism of action
Apixaban is a highly selective, orally bioavailable, and reversible direct inhibitor of free and clot-bound factor Xa. Factor Xa catalyzes the conversion of prothrombin to thrombin, the final enzyme in the coagulation cascade that is responsible for fibrin clot formation. Apixaban has no direct effect on platelet aggregation, but by inhibiting factor Xa, it indirectly decreases platelet formation induced by thrombin.
A new drug application (NDA) for the approval of apixaban was submitted to the FDA by Bristol-Myers Squibb and Pfizer jointly after conclusion of the ARISTOTLE clinical trial in 2011. The drug was initially given priority review status with a hearing date set for March 28, 2012. However, this decision date was postponed to June 28, 2012 while the FDA requested additional information. The agency then delayed the decision another six months, until December 28. 2012, while it requested more information on the storage and accuracy of data from the clinical trial.
A December 2012 memo from FDA reviewer Thomas Marciniak indicates clinical trial data submitted to the agency for apixaban was missing information from approximately 300 patients.
Apixaban was approved for the prevention of stroke in people with atrial fibrillation on December 28, 2012. On March 14, 2014, it was approved for the additional use of preventing deep vein thrombosis and pulmonary embolism in people that had recently undergone knee or hip replacement. On August 21, 2014, the FDA approved apixaban for the treatment of recurring deep vein thrombosis and pulmonary embolism.
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