Not sure if I took my Eliquis - what to do?

This is theoretical and not an actual problem at the moment.

Normally, I am very good about how I put my meds and supps out in a pill box but sometimes life gets busy and I didn't lay them out for the week. At the same time, there are about 5 essential meds I take so I'll just do them one by one out of the bottles. As it's most important, I usually take the Eliquis first and then the other pills but sometimes I get confused and wonder if I took the Eliquis.

So pretending that it 6:00 PM and I am relatively unsure if I took an Eliquis, what should I do?

Take one right away?

Take one late as possible in the night? Like 10PM bedtime or when I first wake up for nature break?

Or just take one at 6:00 AM when I wake up?

Essentially - where is the greatest risk from? From taking two or going 24 hours without?

Assume CHA2DS2-VASc Score of 1.

Different answer for someone with risk of 4?

Quote
Eliquis.com
• Missed dose: If a dose of ELIQUIS® (apixaban) is not taken at the scheduled time, the dose
should be taken as soon as possible on the same day and twice-daily administration should
be resumed. The dose should not be doubled to make up for a missed dose

Source: [www.eliquis.com]

Quote
NHS (UK)
If you're taking apixaban or dabigatran twice a day and you miss one of your doses, you should take it as soon as you remember if it's still more than 6 hours until your next scheduled dose. If it's less than 6 hours until your next dose, skip the dose you missed and take the next scheduled dose as normal.

Source:[www.nhs.uk]

I actually took a second dose because I didn’t remember and then got nervous so I called up the poison control hotline run by pharmacists. They said not to worry and be sure my next dose is 12 hours later. After the 12 hours I took my next dose and after two days on my new time I went back to my old schedule.

I posted this identical situation here in the past.
[www.afibbers.org]

Carey replied to the other thread that during the original trials, Eliquis was given at a higher dose and not to worry.



Edited 1 time(s). Last edit at 12/29/2022 07:34PM by susan.d.

So it appears the risk is towards taking 2 doses and not in missing a dose.

Seems odd at first glance. Imagine there are women here that weigh as little as 100lbs (2948ml of blood) and could have concentrations that are twice as great as a man that weighs over 200lbs. (6804ml)

[reference.medscape.com]#


Only a small 5.1% get 2.5mg BID.

[www.jacc.org]


"Despite the attractive results with apixaban in the randomized trials, there has been uncertainty about use of the 2.5-mg twice-daily dose of apixaban in the community. According to the ARISTOTLE and AVERROES trial protocols, the majority of patients received apixaban at the standard dose of 5 mg twice daily, and only those who met at least 2 of 3 criteria for dose reduction (age ≥80 years, body weight ≤60 kg, and creatinine level ≥1.5 mg/dl or 133 μmol/l) received the lower dose of 2.5 mg twice daily. Thus, of 11,928 patients randomized to receive apixaban in the 2 trials, only 607 (5.1%) received the lower dose (1,2)."

"So it appears the risk is towards taking 2 doses and not in missing a dose..."

There is carryover for apixaban if a dose is missed. The half-live is about 12 hours, so that means 24 hours later, after the missed dose, you should still have about 25% 'bioavailability.' But it's not that simple. When I see a cardiologist or EP, they invariably ask something like, "How long have you been taking apixaban?" and I answer about five years. "Every day?" Yes, I answer. They want to know two things: how compliant I am about following prescriptions (or why waste their time with me?), and what kind of carryover is there. If I have missed a full day or more, they can assume I'm 'empty'. Or, the inverse: I have a fair whack of it in circulation at any one time, and they can reduce other anticoagulants they might otherwise have wanted me to take, say for surgery.

Doubling up on apixaban doubles the risk of unwanted bleeding, especially bad if its internal, but missing a dose only reduces its intended purpose by about 75%. You're still being protected.

Great responses.

I'm still leaning towards the idea that many people continuously have up to a 2x higher blood concentration and seem to get along fine with out any internal bleeding.

Being over 200lbs, I'd probably wait until bedtime and take a dose which may or may not be my second of the evening. I guess I am more afraid of a stoke in my sleep than of the potential risk of having the same high concentration as many smaller people have all of the time. I am going to keep looking for papers that show where the upper limit is or seems to be.

Interesting note in the above cited paper.

. Patients treated with apixaban 2.5 mg twice daily had higher annual rates of stroke/SEE, major bleeding, and mortality than those treated with 5 mg twice daily

Like always - it's complicated. Here's my take - the standard of don't care applies once again.

Best practice in this should be to consider the weight, CHADS, history, lab work (including HCT!!) and genetics of every patient. Not just script out the same dose to nearly every patient.

The work that is done in research is typically ineffectively carried over in practice.

Has anyone here had their prothrombin time tested and then anticoagulant dosing confirmed or modified?

I've been on Eliquis for a few years now and have not. Just shooting in the dark with my eyes closed.

[www.ncbi.nlm.nih.gov]

Genetics - [pubmed.ncbi.nlm.nih.gov]

[pubmed.ncbi.nlm.nih.gov]

Quote
PavanPharter
So it appears the risk is towards taking 2 doses and not in missing a dose.

No. Apixaban has a huge safe dosage range.

During clinical trials they went as high as 25 mg twice daily, so even 5 pills wouldn't hurt you. Animal testing showed that the LD50 is 4000 mg/kg, so you could probably take a lot more than 5 pills.

Thank Carey. That's the conclusion I was coming to despite the pharma sources. I was merely summing up George's post. I'd still like to have PT tested and have dose adjusted if needed.



Edited 1 time(s). Last edit at 12/30/2022 12:37AM by PavanPharter.

One solution so that this isn't likely to happen....get a daily pill box. Fill it up once/week and then you can see if you took a pill on that day or not.
Only takes a few minutes to fill.

Good luck Barb

Quote
tobherd
One solution so that this isn't likely to happen....get a daily pill box. Fill it up once/week and then you can see if you took a pill on that day or not.
Only takes a few minutes to fill.

Good luck Barb

Yes, I think that is the key for preventing this dilemma. If your prescriptions pills are in the container you can tell which ones you have taken and which ones you have not. Because at least one of my prescriptions seems to be sensitive to moisture, I put them out daily instead of weekly.

Quote
PavanPharter
I'd still like to have PT tested and have dose adjusted if needed.

I think you'll have a hard time finding a doctor willing to do that. PT testing isn't useful with the DOACs so it's just not done. When taken as directed, those meds are always effective.

since this is theoretical.. I thought I'd share what I do which is TOTALLY OCD. I snap a pic with my phone of my meds right when I take them. That way when I am lying in bed, and I think, did I take my pills, I can take a quick peek at my phone. (don't judge me! LOL!). I also do have a pill box so that is the usual way but often that is downstairs and I am in bed wondering....

Quote
tobherd
One solution so that this isn't likely to happen....get a daily pill box. Fill it up once/week and then you can see if you took a pill on that day or not.
Only takes a few minutes to fill.

Good luck Barb

I don’t care for the potential for oxidation of having pills exposed to air for a week in a too big pill box. My husband told me this years ago. Maybe that’s why in Europe they use individual pill vacuum blister packs I speculate. I could be wrong…I did go to the container store and got a container only big enough just for a days worth of pills. I refilled daily in the morning. Then I found something better- I bought pill pouches and I try to push out as much air as I can. Below is for 400 bags. You can label them for the week if you like.
[www.amazon.com]

Exposure of drugs to oxygen:

[www.ncbi.nlm.nih.gov]

[www.researchgate.net]

Quote
susan.d
Maybe that’s why in Europe they use individual pill vacuum blister packs I speculate. I could be wrong

I've purchased Tambocor (branded flec) from Europe in vacuum blister packs since 2008. It remains effective for a long time. As I noted in this post, I converted an episode in June 2022 with some blister packed Tambocor that expired in 2014 (I also have plenty of unexpired flec). It had decreased in potency, perhaps by 1/3. This turned out to be fortunate as I discovered (by how my afib responded to the dose) that I'd been taking more flec than I needed for an on-demand conversion (even though I was within the dosing guidelines for weight).

I’ve missed a dose on numerous occasions, with no I’ll effects. It’s a bit like stopping it for a procedure.
I’ve also stopped taking it for some months after having a haemorrhage in my eye. ( obviously my EP wasn’t happy)
I have stopped taking it since Dec 12 this year as other eye playing up. I’m not advising anyone to do this, because I could come unstuck, however I think missing one dose is reasonably safe as long as you are not in AF.

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JoyWin
I think missing one dose is reasonably safe as long as you are not in AF.

My non-medical observation is it depends on your situation. Those who've had ablation work on their LAA and have not passed the final TEE are in a much higher risk situation (unless they have a Watchman type device).



Edited 1 time(s). Last edit at 01/01/2023 01:54PM by GeorgeN.

A non leaking successful watchman you can temporarily go off. I was allowed 5 days. I recently resumed after 5 days off to try to shrink my hematoma. I noticed I got bloody paper cuts I didn’t get when temporarily off Eliquis. It’s just paper cuts, nothing like a life changing horrific stroke if I didn’t have a watchman, with my high CHADS score, had my LAA ablated and stopped Eliquis completely…

Strokes are horrible especially if Eliquis can lower the risks and one decided to chance it. I witnessed firsthand how my father and brother’s strokes changed their lives and at ages 15-17 I worked two hours a day for two years in a nursing home spoon feeding stroke patients. I ended up coming in on my days off to feed them because of their lack of dependency to feed themselves to survive in their own. A few could die if the weekend staff didn’t have time to feed them and instead just left their food trays on a cart inaccessible to them. It happened frequently so I made the decision to be there 7 days a week helping out. So I know the ramifications of one’s life quality of stroke patients and am compliant with my Eliquis.

Stroke is akin to death but without all of the flowers.