Posology : מינונים

     4.2     Posology and method of administration

Posology

Prevention of stroke and systemic embolism
The recommended dose is 60 mg edoxaban once daily.
Therapy with edoxaban in NVAF patients should be continued long term.
Treatment of DVT, treatment of PE and prevention of recurrent DVT and PE (VTE) The recommended dose is 60 mg edoxaban once daily following initial use of parenteral anticoagulant for at least 5 days (see section 5.1). Edoxaban and initial parenteral anticoagulant should not be administered simultaneously.
The duration of therapy for treatment of DVT and PE (venous thromboembolism (VTE)), and prevention of recurrent VTE should be individualised after careful assessment of the treatment benefit against the risk for bleeding (see section 4.4). Short duration of therapy (at least 3 months) should be based on transient risk factors (e.g. recent surgery, trauma, immobilisation) and longer durations should be based on permanent risk factors or idiopathic DVT or PE.

For NVAF and VTE the recommended dose is 30 mg edoxaban once daily in patients with one or more of the following clinical factors:
฀     Moderate or severe renal impairment (creatinine clearance (CrCl) 15 - 50 mL/min)
• Low body weight ≤ 60 kg
• Concomitant use of the following P-glycoprotein (P-gp) inhibitors: ciclosporin, dronedarone, erythromycin, or ketoconazole.

Table 1: Summary of posology in NVAF and VTE (DVT and PE)
Summary guide for dosing
60 mg edoxaban
Recommended dose once daily
Dose recommendation for patients with one or more of the following clinical factors: 
Renal impairment         Moderate or severe (CrCl 15 – 50 mL/min)
30 mg edoxaban
Low body weight         ≤ 60 kg                                                 once daily Ciclosporin, dronedarone, erythromycin,
P-gp inhibitors ketoconazole

Missed dose
If a dose of edoxaban is missed, the dose should be taken immediately and then be continued the following day with the once-daily intake as recommended. The patient should not take double the prescribed dose on the same day to make up for a missed dose.

Switching to and from edoxaban
Continued anticoagulant therapy is important in patients with NVAF and VTE. There may be situations that warrant a change in anticoagulation therapy (Table 2).
Table 2: Switching of anticoagulant treatment in NVAF and VTE (DVT and PE) 
Switching to edoxaban

From                   To                            Recommendation
Vitamin K antagonist                       Discontinue the VKA and start edoxaban when the Edoxaban
(VKA)                              international normalised ratio (INR) is ≤ 2.5.
Oral anticoagulants
other than VKA                   Discontinue dabigatran, rivaroxaban or apixaban and start •      dabigatran    Edoxaban   edoxaban at the time of the next dose of the oral •      rivaroxaban              anticoagulant (see section 5.1).
•      apixaban
These medicinal products should not be administered simultaneously.
Subcutaneous anticoagulant (i.e. low molecular weight heparin (LMWH), fondaparinux):
Parenteral
Edoxaban   Discontinue subcutaneous anticoagulant and start anticoagulants edoxaban at the time of the next scheduled subcutaneous anticoagulant dose.
Intravenous unfractionated heparin (UFH):
Discontinue the infusion and start edoxaban 4 hours later.
Switching from edoxaban

From             To                           Recommendation
There is a potential for inadequate anticoagulation during the transition from edoxaban to VKA.
Continuous adequate anticoagulation should be ensured during any transition to an alternate anticoagulant.

Oral option: For patients currently on a 60 mg dose,
administer an edoxaban dose of 30 mg once daily together with an appropriate VKA dose.
For patients currently on a 30 mg dose (for one or more of the following clinical factors: moderate to severe renal impairment (CrCl 15 – 50 mL/min), low body weight, or use with certain P-gp inhibitors),
administer an edoxaban dose of 15 mg once daily together with an appropriate VKA dose.

Patients should not take a loading dose of VKA in order to promptly achieve a stable INR between 2 and 3. It is recommended to take into account the
Edoxaban maintenance dose of VKA and if the patient was previously taking a VKA or to use valid INR driven
VKA treatment algorithm, in accordance with local
VKA practice.

Once an INR ≥ 2.0 is achieved, edoxaban should be discontinued. Most patients (85%) should be able to achieve an INR ≥ 2.0 within 14 days of concomitant administration of edoxaban and VKA. After 14 days it is recommended that edoxaban is discontinued and the VKA continued to be titrated to achieve an INR between 2 and 3.
It is recommended that during the first 14 days of concomitant therapy the INR is measured at least 3 times just prior to taking the daily dose of edoxaban to minimise the influence of edoxaban on INR measurements. Concomitant edoxaban and VKA can increase the INR post edoxaban dose by up to 46%.

Parenteral option: Discontinue edoxaban and administer a parenteral anticoagulant and VKA at the time of the next scheduled edoxaban dose. Once a stable INR of ≥ 2.0 is achieved, the parenteral anticoagulant should be discontinued and the VKA continued.
Discontinue edoxaban and start the non-VKA
Oral anticoagulants
Edoxaban                       anticoagulant at the time of the next scheduled dose other than VKA of edoxaban.
Switching from edoxaban

From                       To                               Recommendation These medicinal products should not be
Parenteral       administered simultaneously. Discontinue edoxaban
Edoxaban anticoagulants     and start the parenteral anticoagulant at the time of the next scheduled dose of edoxaban.

Special populations
Elderly population
No dose reduction is required (see section 5.2).

Renal impairment
Renal function should be assessed in all patients by calculating the CrCl prior to initiation of treatment with edoxaban to exclude patients with end stage renal disease (i.e. CrCl < 15 mL/min), to use the correct edoxaban dose in patients with CrCl 15 – 50 mL/min (30 mg once daily), in patients with CrCl > 50 mL/min (60 mg once daily) and when deciding on the use of edoxaban in patients with increased CrCl (see section 4.4).

Renal function should also be assessed when a change in renal function is suspected during treatment (e.g. hypovolaemia, dehydration, and in case of concomitant use of certain medicinal products).

The method used to estimate renal function (CrCl in mL/min) during the clinical development of edoxaban was the Cockcroft-Gault method. The formula is as follows:

•   For creatinine in µmol/L:
1.23 × (140-age [years]) × weight [kg] (× 0.85 if female) serum creatinine [µmol/L]

•   For creatinine in mg/dL:
(140-age [years]) × weight [kg] (× 0.85 if female)
72 × serum creatinine [mg/dL]

This method is recommended when assessing patients’ CrCl prior to and during edoxaban treatment.

In patients with mild renal impairment (CrCl > 50 – 80 mL/min), the recommended dose is 60 mg edoxaban once daily.

In patients with moderate or severe renal impairment (CrCl 15 – 50 mL/min), the recommended dose is 30 mg edoxaban once daily (see section 5.2).

In patients with end stage renal disease (ESRD) (CrCl < 15 mL/min) or on dialysis, the use of edoxaban is not recommended (see sections 4.4 and 5.2).

Hepatic impairment
Edoxaban is contraindicated in patients with hepatic disease associated with coagulopathy and clinically relevant bleeding risk (see section 4.3).

In patients with severe hepatic impairment edoxaban is not recommended (see sections 4.4 and 5.2).

In patients with mild to moderate hepatic impairment the recommended dose is 60 mg edoxaban once daily (see section 5.2). Edoxaban should be used with caution in patients with mild to moderate hepatic impairment (see section 4.4).
Patients with elevated liver enzymes (alanine aminotransferase (ALT) or aspartate transaminase (AST) > 2 x upper limit of normal (ULN)) or total bilirubin ≥ 1.5 x ULN, were excluded in clinical studies.
Therefore edoxaban should be used with caution in this population (see sections 4.4 and 5.2). Prior to initiating edoxaban, liver function testing should be performed.

Body weight
For patients with body weight ≤ 60 kg, the recommended dose is 30 mg edoxaban once daily (see section 5.2).

Gender
No dose reduction is required (see section 5.2).

Concomitant use of Lixiana with P-glycoprotein (P-gp) inhibitors
In patients concomitantly taking Lixiana and the following P-gp inhibitors: ciclosporin, dronedarone, erythromycin, or ketoconazole, the recommended dose is 30 mg Lixiana once daily (see section 4.5).
No dose reduction is required for concomitant use of amiodarone, quinidine or verapamil (see section 4.5).
The use of Lixiana with other P-gp inhibitors including HIV protease inhibitors has not been studied.


Patients undergoing cardioversion
Lixiana can be initiated or continued in patients who may require cardioversion. For transoesophageal echocardiogram (TEE) guided cardioversion in patients not previously treated with anticoagulants, Lixiana treatment should be started at least 2 hours before cardioversion to ensure adequate anticoagulation (see sections 5.1 and 5.2). Cardioversion should be performed no later than 12 hours after the dose of Lixiana on the day of the procedure.
For all patients undergoing cardioversion: Confirmation should be sought prior to cardioversion that the patient has taken Lixiana as prescribed. Decisions on initiation and duration of treatment should follow established guidelines for anticoagulant treatment in patients undergoing cardioversion.

Paediatric population
Edoxaban is not recommended for use in children and adolescents from birth to 18 years of age with confirmed VTE (PE and/or DVT) event as the efficacy has not been established. Available data in VTE patients are described in sections 4.8, 5.1 and 5.2.


Method of administration
For oral use.
Edoxaban can be taken with or without food (see section 5.2).

For patients who are unable to swallow whole tablets, Lixiana tablets may be crushed and mixed with water or apple puree and immediately administered orally (see section 5.2).

Alternatively, Lixiana tablets may be crushed and suspended in a small amount of water and immediately delivered through a nasogastric tube or gastric feeding tube after which it should be flushed with water (see section 5.2). Crushed Lixiana tablets are stable in water and apple puree for up to 4 hours.