*Purpose: Atrial arrhythmias and venous thromboembolism (VTE) are common after lung transplant. While direct acting oral anticoagulants (DOACs) have become anticoagulants of choice in atrial arrhythmias and VTE, safety and efficacy have not been established in lung transplant, where drug interactions with DOACs are also often present. This study sought to evaluate outcomes with apixaban use after lung transplant.

*Methods: We retrospectively reviewed consecutive adult lung transplant recipients between October 15, 2015 and December 31, 2018. Patients were included if they received apixaban for 30 days or more for VTE or atrial arrhythmias, and had 12 months of documented follow-up from the start of apixaban. The primary outcome was a composite of adverse events defined as major bleeding, clinically relevant non-major bleeding (CRNMB), recurrent or breakthrough VTE, and stroke. Bleeding was classified as major or CRNMB using criteria set by the International Society on Thrombosis and Haemostasis.

*Results: Twenty-eight patients received apixaban. Fifteen patients received concomitant CYP3A4 or P-gp inhibitors, and 4 of these patients received strong CYP3A4 inhibitors. Six patients (20%) were started on reduced doses for drug interactions or based on clinical judgement. The primary composite endpoint occurred in two patients (7.1%). One CRNMB event occurred in a patient with a gastrointestinal bleed secondary to gastric ulcer, and another patient developed breakthrough lower extremity DVT on apixaban. Drug interactions were not present in the patient who experienced CRNMB. Dose reduction of the loading dose was observed in the recurrent DVT event. No patient experienced a stroke during the follow-up.

*Conclusions: Apixaban appears safe and effective in lung transplant patients. Appropriate dosing and adjusting for interactions are critical for optimal outcomes. Larger studies are warranted to assess long-term outcomes as well as safety and efficacy of alternative DOACs.

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