Eliquis (apixaban) side effects: what you need to know

Eliquis (apixaban) works by inhibiting factor Xa in the clotting cascade, which thins the blood and prevents clot formation.

Because the medicine reduces your blood's ability to clot, the most common side effects are related to bleeding.

Common side effects (affecting up to 1 in 10 people):

• Bruising: you may notice bruises appearing more easily or taking longer to fade
• Nosebleeds (epistaxis): one of the most frequently reported bleeding events
• Bleeding from gums: particularly noticeable when brushing teeth
• Blood in urine (haematuria): which may appear pink or red
• Anaemia: caused by chronic low-level blood loss; symptoms include tiredness, pallor and shortness of breath

Other common side effects:

• Nausea
• Skin rash or itching

The BNF notes that the overall incidence of major bleeding with apixaban is lower than with warfarin, which is one of the main reasons it has become the most commonly prescribed anticoagulant on the NHS.

However, any anticoagulant carries an inherent bleeding risk that must be weighed against its benefits.

The most important risk of Eliquis is serious bleeding. While rare, it can be life-threatening if not recognised and treated promptly.

Signs of serious bleeding include:

• Black or tarry stools (melaena): indicates bleeding in the upper gastrointestinal tract
• Vomiting blood or material that looks like coffee grounds
• Coughing up blood (haemoptysis)
• Severe or prolonged nosebleeds that do not stop with simple pressure
• Blood in urine that is dark red or persistent
• Unusually heavy menstrual periods
• Sudden severe headache, confusion, weakness or numbness: these may indicate bleeding in the brain (intracranial haemorrhage)
• Unexplained swelling or bruising, particularly in the abdomen

If you experience any of these symptoms, seek emergency medical help immediately (call 999).

Since 2019, a specific reversal agent for apixaban has been available in the UK: andexanet alfa (Ondexxya).

This can rapidly reverse the anticoagulant effect in life-threatening or uncontrolled bleeding situations. Hospital emergency departments are equipped to manage anticoagulant-related bleeding.

Beyond bleeding, Eliquis has a small number of other potential side effects.

Uncommon side effects (affecting up to 1 in 100 people):

• Low blood pressure (hypotension)
• Abnormal liver function tests
• Allergic reactions such as skin rash, itching or swelling
• Gastrointestinal bleeding that is not clinically significant but detected on testing

Rare side effects (affecting up to 1 in 1,000 people):

• Allergic reactions including angioedema
• Bleeding into the eye
• Bleeding into the peritoneal cavity
• Haemoptysis (coughing up blood)

It is important to note what Eliquis does not commonly cause:

• Unlike warfarin, apixaban does not require regular INR blood tests
• Unlike warfarin, there are very few food interactions (no need to worry about vitamin K intake)
• Hair loss, a side effect occasionally reported with warfarin, is not associated with Eliquis

These practical advantages contribute to why NICE and NHS England have endorsed DOACs as the anticoagulants of choice for most patients with atrial fibrillation or venous thromboembolism.

While Eliquis is one of the safest anticoagulants available, certain factors increase the risk of bleeding.

Patient-related risk factors:

• Age over 75 years
• Low body weight (under 60 kg)
• Kidney impairment (reduced apixaban clearance)
• Liver disease (impaired production of clotting factors)
• History of gastrointestinal bleeding or peptic ulcer disease
• History of stroke or transient ischaemic attack
• Uncontrolled high blood pressure
• Thrombocytopenia (low platelet count)

Medicine-related risk factors:

• Concurrent use of antiplatelet agents (aspirin, clopidogrel)
• NSAIDs (ibuprofen, naproxen)
• Other anticoagulants (accidental overlap)
• SSRIs and SNRIs (which affect platelet function)
• Strong CYP3A4 and P-glycoprotein inhibitors (ketoconazole, ritonavir)

The BNF recommends using the **2.

5 mg twice daily** dose (instead of the standard 5 mg twice daily) in patients with at least two of the following: age 80 or over, body weight 60 kg or under, or serum creatinine 133 micromol/L or above.

For more details, see our Eliquis dosage guide.

Living safely with Eliquis requires awareness and a few practical precautions.

Reducing your bleeding risk:

• Use a soft-bristled toothbrush and waxed dental floss
• Use an electric razor rather than wet shaving
• Take care with sharp objects, including kitchen knives and garden tools
• Wear protective gloves when gardening
• Avoid contact sports or high-injury-risk activities
• Apply firm pressure for at least 10 minutes to any cut

Medication management:

• Take Eliquis at the same times each day (morning and evening) to maintain a stable blood level
• Do not skip doses, as gaps in anticoagulation increase your risk of blood clots
• Avoid aspirin and ibuprofen unless specifically prescribed by your doctor; paracetamol is the preferred painkiller
• Always tell healthcare professionals (dentists, surgeons, nurses) that you are taking an anticoagulant

Carrying identification:

• The NHS provides an anticoagulant alert card; carry this with you at all times
• Consider wearing a medical alert bracelet
• Ensure your family members know you are taking a blood thinner

If you have a minor bleed:

Small bruises, minor nosebleeds and slight gum bleeding are expected and usually do not require medical attention. Apply pressure and allow time for the bleeding to stop.

Knowing when bleeding requires urgent attention could save your life.

Call 999 or go to A&E immediately if you experience:

• A fall or significant head injury (even if you feel fine initially)
• Signs of internal bleeding: black or bloody stools, vomiting blood, coughing up blood
• A sudden severe headache with no obvious cause
• Sudden weakness, numbness or difficulty speaking (possible stroke)
• Bleeding that does not stop after 10 to 15 minutes of firm pressure
• Signs of severe allergic reaction: swelling of face or throat, difficulty breathing

Contact your GP or call 111 if you notice:

• Frequent or prolonged nosebleeds
• Unusual or increased bruising
• Pink or red urine that persists
• Heavy menstrual periods that are significantly worse than usual
• Persistent tiredness or pallor (possible anaemia)

Before any medical or dental procedure:

Always inform the treating clinician that you take Eliquis. Your anticoagulant may need to be temporarily stopped before certain procedures.

Your GP or anticoagulation clinic will advise on the appropriate stopping and restart times.