ASH Clinical News July 2016

SELECTED IMPORTANT SAFETY INFORMATION WARNING: (A) PREMATURE DISCONTINUATION OF ELIQUIS INCREASES THE RISK OF THROMBOTIC EVENTS, (B) SPINAL/ EPIDURAL HEMATOMA (A) Premature discontinuation of any oral anticoagulant, including ELIQUIS, increases the risk of thrombotic events. If anticoagulation with ELIQUIS is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant. (B) Epidural or spinal hematomas may occur in patients treated with ELIQUIS who are receiving neuraxial anesthesia or undergoing spinal puncture. These hematomas may result in long-term or permanent paralysis. Consider these risks when scheduling patients for spinal procedures. Factors that can increase the risk of developing epidural or spinal hematomas in these patients include: • use of indwelling epidural catheters • concomitant use of other drugs that affect hemostasis, such as nonsteroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors, other anticoagulants • a history of traumatic or repeated epidural or spinal punctures • a history of spinal deformity or spinal surgery • optimal timing between the administration of ELIQUIS and neuraxial procedures is not known Monitor patients frequently for signs and symptoms of neurological impairment. If neurological compromise is noted, urgent treatment is necessary. Consider the benefits and risks before neuraxial intervention in patients anticoagulated or to be anticoagulated. • Spinal/Epidural Anesthesia or Puncture: Patients treated with ELIQUIS undergoing spinal/epidural anesthesia or puncture may develop an epidural or spinal hematoma which can result in long-term or permanent paralysis. The risk of these events may be increased by the postoperative use of indwelling epidural catheters or the concomitant use of medicinal products affecting hemostasis. Indwelling epidural or intrathecal catheters should not be removed earlier than 24 hours after the last administration of ELIQUIS. The next dose of ELIQUIS should not be administered earlier than 5 hours after the removal of the catheter. The risk may also be increased by traumatic or repeated epidural or spinal puncture. If traumatic puncture occurs, delay the administration of ELIQUIS for 48 hours. Monitor patients frequently and if neurological compromise is noted, urgent diagnosis and treatment is necessary. Physicians should consider the potential benefit versus the risk of neuraxial intervention in ELIQUIS patients. • Prosthetic Heart Valves: The safety and efficacy of ELIQUIS have not been studied in patients with prosthetic heart valves and is not recommended in these patients. • Acute PE in Hemodynamically Unstable Patients or Patients who Require Thrombolysis or Pulmonary Embolectomy: Initiation of ELIQUIS is not recommended as an alternative to unfractionated heparin for the initial treatment of patients with PE who present with hemodynamic instability or who may receive thrombolysis or pulmonary embolectomy. ADVERSE REACTIONS • The most common and most serious adverse reactions reported with ELIQUIS were related to bleeding. TEMPORARY INTERRUPTION FOR SURGERY AND OTHER INTERVENTIONS • ELIQUIS should be discontinued at least 48 hours prior to elective CONTRAINDICATIONS surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding. ELIQUIS should be • Active pathological bleeding discontinued at least 24 hours prior to elective surgery or invasive • Severe hypersensitivity reaction to ELIQUIS (e.g., anaphylactic reactions) procedures with a low risk of bleeding or where the bleeding would be WARNINGS AND PRECAUTIONS noncritical in location and easily controlled. Bridging anticoagulation • Increased Risk of Thrombotic Events After Premature Discontinuation: during the 24 to 48 hours after stopping ELIQUIS and prior to the Premature discontinuation of any oral anticoagulant, including ELIQUIS, intervention is not generally required. ELIQUIS should be restarted after in the absence of adequate alternative anticoagulation increases the the surgical or other procedures as soon as adequate hemostasis has risk of thrombotic events. An increased rate of stroke was observed been established. during the transition from ELIQUIS to warfarin in clinical trials in atrial DRUG INTERACTIONS fibrillation patients. If ELIQUIS is discontinued for a reason other than • Strong Dual Inhibitors of CYP3A4 and P-gp: Inhibitors of cytochrome pathological bleeding or completion of a course of therapy, consider P450 3A4 (CYP3A4) and P-glycoprotein (P-gp) increase exposure to apixaban coverage with another anticoagulant. and increase the risk of bleeding. For patients receiving ELIQUIS doses of • Bleeding Risk: ELIQUIS increases the risk of bleeding and can cause 5 mg or 10 mg twice daily, reduce the dose of ELIQUIS by 50% when serious, potentially fatal, bleeding. ELIQUIS is coadministered with drugs that are strong dual inhibitors of – Concomitant use of drugs affecting hemostasis increases the risk of CYP3A4 and P-gp (e.g., ketoconazole, itraconazole, ritonavir, or bleeding, including aspirin and other antiplatelet agents, other clarithromycin). In patients already taking 2.5 mg twice daily, avoid anticoagulants, heparin, thrombolytic agents, SSRIs, SNRIs, and coadministration of ELIQUIS with strong dual inhibitors of CYP3A4 and P-gp. NSAIDs. • Strong Dual Inducers of CYP3A4 and P-gp: Avoid concomitant use of – Advise patients of signs and symptoms of blood loss and to report ELIQUIS with strong dual inducers of CYP3A4 and P-gp (e.g., rifampin, them immediately or go to an emergency room. Discontinue ELIQUIS carbamazepine, phenytoin, St. John’s wort) because such drugs will in patients with active pathological hemorrhage. decrease exposure to apixaban and increase the risk of stroke and other thromboembolic events. – There is no established way to reverse the anticoagulant effect of apixaban, which can be expected to persist for at least 24 hours after the last dose (i.e., about two half-lives). A specific antidote for ELIQUIS is not available. Please see Brief Summary of Full Prescribing Information, including Boxed WARNINGS, on the adjacent pages. ELIQUIS® and the ELIQUIS logo are trademarks of Bristol-Myers Squibb Company. © 2015 Bristol-Myers Squibb Company. All rights reserved. 432US15BR01135-02-01 10/15

ASH Clinical News July 2016 | Page 10