Combination Therapy with Apixaban and Aspirin

Introduction to Combination Therapy

• The American Heart Association recommends that apixaban and aspirin can be used together in specific clinical situations, such as acute coronary syndrome (ACS), recent percutaneous coronary intervention (PCI), or stable coronary/peripheral artery disease, but this combination significantly increases bleeding risk and should only be employed when there is a clear indication for dual therapy 1

Key Evidence for Combination Therapy

• The European Society of Cardiology states that concomitant aspirin increases bleeding risk on apixaban from 1.8% to 3.4% per year 1
• The American College of Cardiology recommends that "triple therapy" (aspirin + P2Y12 inhibitor + anticoagulant) is no better than dual therapy (P2Y12 inhibitor + anticoagulant) at preventing thrombotic events but causes significantly more bleeding 2

Indications for Combination Therapy

• The American Heart Association suggests that for patients with atrial fibrillation requiring anticoagulation who experience ACS or undergo PCI, use apixaban with a P2Y12 inhibitor (clopidogrel preferred) WITHOUT aspirin for the majority of patients 2
• The European Society of Cardiology recommends that triple therapy should be reserved only for patients at exceptionally high risk of stent thrombosis and should not exceed 30 days 2

Duration of Combination Therapy

• The American College of Cardiology recommends the following duration of combination therapy:

Alternative Therapies

• The European Society of Cardiology states that combination therapy with aspirin plus low-dose rivaroxaban (not apixaban) may be considered for stable coronary and/or peripheral artery disease 3, 1
• The American Heart Association recommends that aspirin should NOT be used with apixaban for stroke prevention in atrial fibrillation alone 4

Safety Considerations

• The American College of Cardiology recommends that proton pump inhibitor prophylaxis should be initiated in all patients on simultaneous antiplatelet and anticoagulant therapy 2