Axiorex (Tablets) Instructions for Use

Marketing Authorization Holder

Polpharma Pharmaceutical Works, Sa (Poland)

ATC Code

B01AF02 (Apixaban)

Active Substance

Apixaban (Rec.INN registered by WHO)

Dosage Forms

	Axiorex	Film-coated tablets, 2.5 mg: 20 or 60 pcs.
		Film-coated tablets, 5 mg: 20 or 60 pcs.

Dosage Form, Packaging, and Composition

Film-coated tablets light yellow in color, round, biconvex; the tablet core on the cross-section is white or almost white.

Excipients: mannitol, microcrystalline cellulose, sodium lauryl sulfate – 2 mg, croscarmellose sodium – 2 mg, magnesium stearate.

Film coating composition ready film coating “Opadry II yellow”: hypromellose 2910, titanium dioxide (E171), lactose monohydrate – 0.84 mg, macrogol MW3350, triacetin, iron oxide yellow dye (E172).

10 pcs. – blister packs (2) – cardboard packs.
10 pcs. – blister packs (6) – cardboard packs.
20 pcs. – blister packs (1) – cardboard packs.
20 pcs. – blister packs (3) – cardboard packs.

Film-coated tablets pink in color, oblong, biconvex; the tablet core on the cross-section is white or almost white.

Excipients: mannitol, microcrystalline cellulose, sodium lauryl sulfate – 4 mg, croscarmellose sodium – 4 mg, magnesium stearate.

Film coating composition ready film coating “Opadry II pink”: hypromellose 2910, titanium dioxide (E171), lactose monohydrate – 1.68 mg, macrogol MW3350, triacetin, iron oxide red dye (E172), iron oxide yellow dye (E172), iron oxide black dye (E172).

10 pcs. – blister packs (2) – cardboard packs.
10 pcs. – blister packs (6) – cardboard packs.

Clinical-Pharmacological Group

Anticoagulant – direct factor Xa inhibitor

Pharmacotherapeutic Group

Antithrombotic agents; direct factor Xa inhibitors

Pharmacological Action

Direct-acting anticoagulant, selective inhibitor of blood coagulation factor Xa.

The mechanism of action of apixaban involves inhibiting the activity of blood coagulation factor Xa, reversibly and selectively blocking the active site of the enzyme. The presence of antithrombin III is not required for the antithrombotic effect of apixaban to be realized. Apixaban inhibits free and bound coagulation factor Xa, as well as prothrombinase activity. Apixaban does not have a direct effect on platelet aggregation, but indirectly inhibits thrombin-induced platelet aggregation.

By inhibiting the activity of coagulation factor Xa, Apixaban prevents the formation of thrombin and blood clots. Apixaban alters the values of blood coagulation system parameters: prolongs prothrombin time, INR, and aPTT.

Pharmacokinetics

After oral administration, Apixaban is rapidly absorbed from the gastrointestinal tract. C_max is reached within 3-4 hours. The absolute bioavailability of apixaban reaches 50% when used in doses up to 10 mg. Food intake does not affect the AUC or C_max of apixaban. The pharmacokinetics of apixaban for doses up to 10 mg is linear. When apixaban is taken in doses greater than 25 mg, a decrease in absorption is noted, accompanied by a decrease in bioavailability.

The metabolism parameters of apixaban are characterized by low or moderate inter- and intra-individual variability (the corresponding coefficient of variability values are 20% and 30%).

The binding of apixaban to human plasma proteins is approximately 87%, V_ss is approximately 21 L.

About 25% of the administered dose is excreted as metabolites, mostly through the intestines. Renal excretion of apixaban accounts for approximately 27% of its total clearance.

The total clearance of apixaban is approximately 3.3 L/h, T_1/2 is about 12 hours. O-demethylation and hydroxylation at the 3-oxopiperidinyl residue are the main pathways of apixaban biotransformation. Apixaban is predominantly metabolized with the participation of the CYP3A4/5 isoenzyme, and to a lesser extent by the CYP1A2, 2C8, 2C9, 2C19, and 2J2 isoenzymes. Unchanged Apixaban is the main substance circulating in human plasma; there are no active circulating metabolites in the bloodstream. In addition, Apixaban is a substrate for transport proteins, P-glycoprotein and breast cancer resistance protein (BCRP).

Indications

Prevention of venous thromboembolism in patients after elective hip or knee replacement surgery.

Prevention of strokes, systemic thromboembolism, and reduction of mortality in patients with atrial fibrillation (except for patients with severe and moderate mitral stenosis or with artificial heart valves).

ICD codes

Dosage Regimen

Take orally, with or without food.

For stroke prevention in non-valvular atrial fibrillation, the recommended dose is 5 mg twice daily.

Reduce the dose to 2.5 mg twice daily in patients with at least two of the following characteristics: age 80 years or older, body weight 60 kg or less, or serum creatinine 1.5 mg/dL or greater.

For postoperative prophylaxis of venous thromboembolism following hip or knee replacement surgery, the recommended dose is 2.5 mg twice daily.

Initiate the first dose 12 to 24 hours after surgery, provided hemostasis has been established.

For hip replacement surgery, the recommended duration of treatment is 32 to 38 days.

For knee replacement surgery, the recommended duration of treatment is 10 to 14 days.

For treatment of deep vein thrombosis and pulmonary embolism, the recommended dose is 10 mg twice daily for the first 7 days, followed by 5 mg twice daily for long-term therapy.

For reduction in the risk of recurrent DVT and PE, the recommended dose is 2.5 mg twice daily following 6 months of initial treatment.

Do not break or crush tablets. Swallow the tablet whole with water.

If a dose is missed, take it as soon as possible on the same day and then continue with the twice-daily regimen. Do not double the dose to make up for a forgotten one.

Discontinue therapy prior to invasive or surgical procedures if clinically appropriate, based on the procedure’s bleeding risk and the patient’s thromboembolic risk.

Adverse Reactions

From the hematopoietic system: often – anemia (including postoperative and post-hemorrhagic, accompanied by corresponding changes in laboratory test results); infrequently – thrombocytopenia (including decreased platelet count).

Allergic reactions rarely – hypersensitivity.

From the organ of vision rarely – hemorrhages in the tissues of the eyeball (including conjunctival hemorrhage).

From the cardiovascular system: often – bleeding (including hematoma, vaginal and urethral bleeding); infrequently – arterial hypotension (including hypotension during the procedure).

From the respiratory system infrequently – nosebleed; rarely – hemoptysis.

From the digestive system often – nausea; infrequently – gastrointestinal bleeding (including vomiting with blood and melena), presence of unchanged blood in the stool, increased transaminase activity (including ALT, AST, GGT), alkaline phosphatase in the blood, increased bilirubin concentration in the blood; rarely – rectal bleeding, gum bleeding.

From the musculoskeletal system rarely – muscle hemorrhage.

From the urinary system infrequently – hematuria (including corresponding changes in laboratory test results).

Other often – closed trauma; infrequently – hemorrhages and bleeding after invasive procedures (including post-procedural hematoma, postoperative wound bleeding, hematoma at the vessel puncture site and catheter insertion site), presence of wound discharge, hemorrhage at the incision site (including hematoma at the incision site), bleeding during surgery.

Contraindications

Clinically significant active bleeding; severe liver dysfunction; renal impairment with CrCl <15 ml/min, as well as use in patients on dialysis; presence of a lesion or condition associated with a high risk of massive bleeding; pregnancy, lactation (breastfeeding); children and adolescents under 18 years of age; simultaneous use with other anticoagulants (except when unfractionated heparin is administered in doses necessary to maintain the patency of a central venous or arterial catheter); hypersensitivity to apixaban.

Use in Pregnancy and Lactation

The use of apixaban is contraindicated during pregnancy and lactation (breastfeeding).

Pediatric Use

The drug is contraindicated for use in children and adolescents under 18 years of age.

Special Precautions

Apixaban should be used with caution during spinal, epidural anesthesia, or punctures; in patients receiving systemic therapy with potent inhibitors of the CYP3A4 isoenzyme and P-glycoprotein, such as azole antifungals (including ketoconazole, itraconazole, voriconazole, and posaconazole), HIV protease inhibitors (e.g., ritonavir); in patients receiving potent inducers of the CYP3A4 isoenzyme and P-glycoprotein (including rifampicin, phenytoin, carbamazepine, phenobarbital, St. John’s wort preparations); in conditions characterized by an increased risk of bleeding, including congenital or acquired coagulation disorders, exacerbations of gastrointestinal ulcers, bacterial endocarditis, thrombocytopenia, thrombocytopathies; history of hemorrhagic stroke; recent surgery on the brain or spinal cord, as well as on the organ of vision; in severe uncontrolled arterial hypertension; in patients with mild and moderate hepatic insufficiency (Child-Pugh class A or B); with increased activity of liver enzymes (ALT, AST more than 2 times the ULN) or an increase in total bilirubin content by 1.5 times or more the ULN; in patients with renal impairment; simultaneously with NSAIDs (including acetylsalicylic acid), as these drugs increase the risk of bleeding; in elderly patients.

If severe bleeding develops, Apixaban should be discontinued. If hemorrhagic complications develop, it is necessary to discontinue Apixaban and perform an examination to identify the source of bleeding. If necessary, appropriate treatment should be prescribed, in particular, surgical hemostasis or transfusion of fresh frozen plasma.

When performing spinal or epidural anesthesia or diagnostic puncture of these areas in patients receiving antithrombotic agents for the prevention of thromboembolism, there is a risk of developing epidural or spinal hematomas, which, in turn, can cause persistent or irreversible paralysis. This risk may further increase with the use of an indwelling epidural catheter in the postoperative period or with the parallel use of other drugs affecting hemostasis.

A similar increase in risk may be noted when performing traumatic or repeated punctures of the epidural or subarachnoid spaces. Frequent monitoring of patients for the development of manifestations of neurological function impairment (in particular, numbness or weakness of the lower extremities, impaired bowel or bladder function) is necessary. If such disorders develop, emergency examination and treatment should be performed. Before performing interventions on the epidural or subarachnoid spaces in patients receiving anticoagulants, including for the prevention of thrombosis, an assessment of the potential benefit and risk ratio is necessary.

Drug Interactions

With the simultaneous use of apixaban and ketoconazole (at a dose of 400 mg, once daily), which is a potent inhibitor of both the CYP3A4 isoenzyme and P-glycoprotein, an increase in the mean AUC of apixaban by 2 times and the mean C_max by 1.6 times was observed. With this combination, dose adjustment of apixaban is not required, but Apixaban should be used with caution in patients receiving systemic therapy with azole antifungals, in particular ketoconazole, or other potent inhibitors of the CYP3A4 isoenzyme and P-glycoprotein.

Drugs that moderately reduce the excretion rate of apixaban or inhibit the CYP3A4 isoenzyme and/or P-glycoprotein may lead to a lesser increase in the plasma concentration of apixaban. For example, diltiazem (a moderate inhibitor of the CYP3A4 isoenzyme and a weak inhibitor of P-glycoprotein) at a dose of 360 mg once daily led to an increase in the mean AUC of apixaban by 1.4 times and the mean C_max by 1.3 times. Naproxen (a P-glycoprotein inhibitor) when used at a dose of 500 mg in healthy volunteers caused an increase in the mean AUC and C_max of apixaban by 1.5 and 1.6 times, respectively. At the same time, an increase in the values of blood coagulation system parameters was noted.

The combination of apixaban with rifampicin (a potent inducer of the CYP3A4 isoenzyme and P-glycoprotein) led to a decrease in the mean AUC and C_max of apixaban by approximately 54% and 42%, respectively. Apparently, the combination of apixaban with other potent inducers of the CYP3A4 isoenzyme and P-glycoprotein (in particular, phenytoin, carbamazepine, phenobarbital, or St. John’s wort preparations) may also lead to a decrease in the plasma concentration of apixaban. Dose adjustment of apixaban when combined with agents of this group is not required, but these agents should be combined with caution.

After co-administration of enoxaparin (single dose, 40 mg) and apixaban (single dose, 5 mg), an additive effect of these agents on coagulation factor Xa activity was noted.

Combination of apixaban with clopidogrel (at a dose of 75 mg, once daily) or a combination of clopidogrel (75 mg) and acetylsalicylic acid (162 mg, once daily), according to some data, did not lead to an increase in bleeding time, further inhibition of platelet aggregation, or an increase in blood coagulation system parameters (prothrombin time, INR, and aPTT) compared with the use of these antiplatelet agents in monotherapy. However, caution should be exercised when using apixaban simultaneously with NSAIDs (including acetylsalicylic acid), as these drugs increase the risk of bleeding.

Drugs whose action may be associated with the development of serious bleeding, such as thrombolytics, glycoprotein IIb/IIIa receptor antagonists, thienopyridines (e.g., clopidogrel), dipyridamole, dextran, sulfinpyrazone, should not be used simultaneously.

Combination of apixaban (at a dose of 10 mg) with atenolol (at a dose of 100 mg) did not lead to clinically significant changes in the pharmacokinetic parameters of apixaban, but it was accompanied by a decrease in the mean AUC and C_max of apixaban by 15% and 18%, respectively, compared with the monotherapy regimen.

In in vitro studies, Apixaban caused weak suppression of CYP2C19 isoenzyme activity (IC50 > 20 µmol/L) by apixaban at a concentration significantly exceeding the C_max in plasma during its clinical use.

Intake of activated charcoal reduces the exposure of apixaban.

Storage Conditions

Store at 2°C (36°F) to 25°C (77°F). Keep in original packaging, protected from light. Keep out of reach of children.

Dispensing Status

Rx Only

Important Safety Information

This information is for educational purposes only and does not replace professional medical advice. Always consult your doctor before use. Dosage and side effects may vary. Use only as prescribed.