Letter to the Editor 2209
Apixaban Auto-intoxication: Toxicokinetics and
Coagulation Tests
L. Mast1 R.J. Verheul1,2 R. Reijnen1 R.C.J.M. van Rossen3
1 Haaglanden Medical Centre (HMC), The Hague, The Netherlands
2 Clinical Chemistry and Laboratory Medicine, HMC/LabWest,
The Hague, The Netherlands
3 Laboratory Central Hospital Pharmacy (AHZ),
The Hague, The Netherlands
Thromb Haemost 2017;117:2209–2211.
Dear Sirs,
Apixaban is a direct oral anticoagulant (DOAC) that acts on
the coagulation cascade by direct factor Xa inhibition. It is
currently approved for the prevention and treatment of
venous thromboembolism and for the prevention of stroke
and systemic embolism in atrial fibrillation patients.1 Two
case reports have described an apixaban overdose thus far,2,3
and little is known about apixaban toxicokinetics. We pre-
sent an apixaban auto-intoxication with corresponding tox-
icokinetics and coagulation tests.
Case
A 48-year-old woman was presented to the emergency room
(ER) 75 minutes after ingestion of 56 apixaban 5-mg tablets
and a superficial knife cut in her left elbow. No coingestion of
other medication, alcohol or drugs was reported. Other than
a psychiatric history, the patient had no comorbidities (and
thus had no indication for apixaban). The only medication
used on a regular basis was disulfiram three times a week due
to a history of alcohol abuse.
Vital signs and physical examination were normal, except
for the minimally bleeding wound on the left elbow. Renal
and hepatic functions were normal, ethanol level was not
detectable and the bodyweight was 70 kg. The wound was
successfully treated with a single bandage. Administration of
activated charcoal was proposed, but refused by the patient.
No blood products or clotting factors were administered as
the bleeding was only superficial. Only 40-mg esomeprazole
once daily was given prophylactically. The patient was
observed for approximately 3 hours on the ER, followed by
a 29-hour observation on the acute medical psychiatric unit
(equipped with monitoring facilities and personnel trained
in both somatic and psychiatric disorders). Vital signs re-
mained stable and no signs of bleeding, side effects or
complications were observed.
received
July 10, 2017
accepted after revision
August 7, 2017
J.W.P.M. Overdiek1 E.B. Wilms3
Address for correspondence Lodi Mast, MSc, PharmD, Haaglanden
Medical Centre (HMC), The Hague, The Netherlands
(e-mail: l.mast@antoniusziekenhuis.nl).
At eight time points within a course of 25 hours, blood
samples were collected for monitoring of haemoglobin,
prothrombin time (PT), activated partial thromboplastin
time (APTT), apixaban concentrations and chemical analytes
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(e.g., kidney and liver function). Haemoglobin, kidney and
liver function tests remained stable and within the normal
range.
The highest apixaban level was found 5 hours after
ingestion (1,680 ng/mL; ►Fig. 1A). A linear kinetic profile
was observed and the Tmax corresponded with known
apixaban kinetics. The half-life time was approximately 8
hours.
APTT values were not elevated (maximum: 29 seconds;
normal range: 24–32 seconds) and PT values were moder-
ately elevated (maximum: 13.3 seconds; normal range: 9.5–
11.5 seconds). A correlation was seen between apixaban
concentrations and PT values (►Fig. 1B).
Analytical Methods
Coagulation tests were performed on citrated plasma sam-
ples (1.8-mL BD Vacutainer 0.109-M citrate). PT (Dade
Innovin) and APTT (Actin FSL) were analysed directly after
centrifugation on a Sysmex CS2100 system. Consecutive
plasma samples for apixaban anti-Xa activity (3.5-mL BD
Vacutainer 0.105-M citrate) and remnant serum samples for
apixaban concentrations (4-mL BD Vacutainer Cloth Activa-
tion Tube) were obtained by venflon access. Samples were
centrifuged directly after arrival at the in-house laboratory.
The citrated plasma samples were stored at –20°C for several
hours before analysis. Apixaban anti-Xa activity was deter-
mined on a Sysmex CS2100 system using the Biophen
heparin (LRT) reagent kit and corresponding apixaban cali-
brator set (Hyphen). Some samples were diluted up to 20
times to allow adequate optical density readings.
Apixaban serum levels were determined by an liquid
chromatography–mass spectrometry (LC-MS/MS) assay,
Copyright © 2017 Schattauer DOI https://doi.org/
10.1160/TH17-07-0474.
ISSN 0340-6245.
2210 Apixaban Auto-intoxication Mast et al.
Fig. 1 (A) Linear apixaban toxicokinetics were observed. Apixaban
concentrations measured directly by liquid chromatography–mass
spectrometry (LC-MS/MS; dotted line) and derived from the anti-Xa
measurements (solid line) were above reference values (grey dotted
lines). (B) A trend in the correlation between apixaban concentrations
and prothrombin time (PT) values was observed (black dotted line).
For high apixaban levels, PT values above reference values were seen
(grey dotted lines).
after storage for 3 weeks at –20°C. For this assay, UCB17025
was used as an internal standard. Serum samples were
diluted 10 times in acetonitrile/methanol (85% (V/V) acet-
onitrile) before quantification. The compounds were sepa-
rated on a Zorbax Eclipse Plus C18 (2.1
50 mm, 1.8 μm)
column, using a linear gradient with a binary mobile phase of
0.1% formic acid in highly purified water (A) and 0.1% formic
acid in acetonitrile (B).
A triple quadrupole mass spectrometer (Agilent Technol-
ogies 6460) was operating in the ESI (electrospray ioniza-
tion) positive mode and the single charged molecular ion
was used as the precursor ion. The transition ions were m/z
460.2 ! 443.1 for apixaban and 185.1 ! 140.1 for the
internal standard.
Discussion
This is the third case report describing an apixaban overdose.
Apixaban demonstrates linear pharmacokinetics in dosages of
Thrombosis and Haemostasis Vol. 117 No. 11/2017
up to 10 mg.1 In previous case reports, linearity of apixaban
toxicokinetics was subject of discussion. Although the first
publication reported linear kinetics, an increasing elimination
half-life over time was seen in the second publication.2,3 In the
present case report, Tmax values corresponded with known
apixaban kinetics in therapeutic range, while the elimination
half-life was slightly decreased. Furthermore, a linear kinetic
profile was observed. Twenty-four hours after ingestion, apix-
aban levels were around the maximum therapeutic concen-
tration of 251 ng/mL.1
In this case, no prophylactic measures besides gastric
protection were taken. According to local guidelines, clotting
factor replacement was not indicated, since no major bleedings
were observed. An apixaban antidote is still subject of clinical
trials and therefore not yet available.4 During admission,
emergency treatment with clotting factors and blood products
was available for immediate treatment when indicated.
A strong correlation between LC-MS/MS and anti-Xa assay
was observed; however, the anti-Xa assay reported lower
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apixaban concentrations, likely due to a systematic error in
methodology and differences in the matrix (serum vs. citrate
plasma) which have been reported earlier.5
The two assays presented the highest concentration at
slightly different time points. The lack of a measuring point in
the LC-MS/MS assay is possibly accountable for this differ-
ence. The presented data were not edited to estimate the
peak concentration in between the sample points.
As apixaban absorption decreases at doses higher than
25 mg, an accurate estimation of Cmax based on known
kinetic parameters (bioavailability, volume of distribution)
can hardly be made during apixaban intoxication.1 Although
we found similar concentrations as Barton et al, Leikin et al
found a much higher concentration of 2,766 ng/mL, 14 hours
after ingestion of 300-mg apixaban. Differences in metho-
dology, patient characteristics and reliability of the ingested
dose may all contribute to this discrepancy. In the three case
reports, half-life times were comparable (6–8 hours) and
slightly shorter than the T1/2 at therapeutic dosing (12
hours). Leikin et al3 found a prolonged terminal T1/2 (15
hours), which could not be observed in our data.1,2
In supra therapeutic concentrations, we found a moderate
level of correlation between PT values and the apixaban
concentration (R2 ¼ 0.91). However, it is debatable whether
these slightly elevated PT values would adequately alarm and
help ER physicians. Earlier in vitro studies confirmed the lack
of sensitivity for increased apixaban concentrations (up to
500 ng/mL) in our PT and APTT reagents.6,7
With the increasing usage of DOACs, availability of
selective toxicology monitoring techniques is needed. Our
PT and APTT tests showed to be of limited value to quantify
apixaban overdosage, confirming the need for a fast, selec-
tive analytical technique like anti-Xa or LC-MS/MS
determination.
Addendum: Role and Contribution of Each Author
Lodi Mast
First author, coordinator in writing the case report, mer-
ger of discussion points.

Rolf Verheul
Consulted clinical chemist at time of presentation, co-
writer, provider of important input and literature for the
discussion.
Resi Reijnen
Consulted ER doctor at time of presentation, co-writer,
provider of input on describing the case.
Richard van Rossen
Lab technician responsible for LC-MS/MS measurements,
co-writer.
Hans Overdiek
Consulted clinical pharmacologist for proof reading the
manuscript, co-writer.
Erik Wilms
Consulted clinical pharmacologist at time of presentation,
initiator of the case report, supervisor of first author,
provider of direction and structure in the approach of
writing.
Apixaban Auto-intoxication Mast et al. 2211
Conflict of Interest
The authors state that they have no conflict of interest.
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