Savaysa medication guide

edoxaban is restricted to NO SUB orders with patients taking as a home medication and it is judged a higher risk to interchange to apixaban during hospital admission. Defer edoxaban initiation to outpatient setting. Orders will be interchanged based on the guidelines below.

Interchange edoxaban based on the following guidelines:

1. If edoxaban is being prescribed for a new DVT/PE, begin apixaban 10 mg PO BID x 7 days. Then begin apixaban 5 mg PO BID. Otherwise move to Step 2.

2. Determine the indication for NOAC Therapy:

• For DVT/PE maintenance: Begin apixaban 5 mg PO BID
• For Atrial Fibrillation: Begin apixaban 5 mg PO BID
• If 2 or more of the following are present, reduce apixaban to 2.5 mg PO BID
• Age ≥ 80
• Weight ≤ 60 kg
• serum creatinine ≥ 1.5 mg/dL
• Post knee and hip arthroplasty: apixaban 2.5 mg PO BID x 12 days
• If the patient is on any of the following: ketoconazole (systemic), itraconazole, ritonavir, clarithromycin, or cobicistat the above recommended dose of apixaban should be reduced by 50% -- e.g. 5 mg PO BID to 2.5 mg PO BID. If the above recommended dose is already 2.5 mg PO BID, then investigate the following in the order listed:
• See if edoxaban is in stock and NO SUB the order for edoxaban
• See if patient can use own edoxaban
• See if MD can change the interacting med
• Continue with apixaban 2.5 mg PO BID and enter a PKS consult for clinical specialist to investigate further and follow-up with MD
• Note with the above options, it is important the patient does not miss a dose
• If patient is currently on any of the following: riFAMpin, carBAMazepine, phenytoin, fosphenytoin, PHENobarbital, primidone, or St Johns Wort notify MD that NOACS should be avoided with strong 3A4 inducers. If MD insists on continuing a NOAC, substitute edoxaban with apixaban per above indication and enter a PKS consult for a clinical specialist to evaluate for options and follow-up with MD.
• All orders for anticoagulants should be screened carefully for drug interactions not listed above.

Automatic pharmacist dose adjustment per package insert recommendations, not to be given for non-valvular a-fib if CrCl > 95 mL/min or if < 15 mL/min.

Reviewed: 25 March 2015 and 28 Feb 2017

• Micromedex
• UpToDate
• Lippincott Advisor