What is the optimal dose for Apixaban (apixaban) to treat extensive pulmonary embolism and deep vein thrombosis indefinitely?

From the Guidelines

For indefinite treatment of extensive pulmonary embolism (PE) and deep vein thrombosis (DVT), the optimal dose of apixaban is 2.5 mg taken orally twice daily, as this reduced dose has been recommended for secondary prevention of recurrent VTE after completion of the primary treatment phase, according to the most recent guidelines 1. This recommendation is based on the American Society of Hematology 2020 guidelines for management of venous thromboembolism, which suggest that the standard dose or the lower dose of rivaroxaban or apixaban may be used for the secondary prevention of VTE, with a moderate certainty in the evidence of effects 1. Additionally, the 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism recommend that if extended oral anticoagulation is decided after PE in a patient without cancer, a reduced dose of the NOACs apixaban (2.5 mg b.i.d.) or rivaroxaban (10 mg o.d.) should be considered after 6 months of therapeutic anticoagulation 1. The most recent update of the CHEST guideline and expert panel report also recommends reduced-dose DOAC over aspirin or no therapy for extended-phase anticoagulation, with apixaban 2.5 mg twice daily being a recommended reduced dose 1. It is essential to note that the choice of dose should be individualized based on patient-specific factors, such as renal function, body weight, and bleeding risk. Regular monitoring of renal function, complete blood counts, and clinical assessment for bleeding or recurrent thrombosis is crucial during indefinite therapy. Apixaban works by directly inhibiting Factor Xa, preventing the conversion of prothrombin to thrombin and thus inhibiting clot formation, making it effective for long-term prevention of recurrent venous thromboembolism. Some key points to consider when prescribing apixaban include:

• Initial treatment phase: 10 mg twice daily for the first 7 days
• Maintenance dose: 2.5 mg twice daily for secondary prevention of recurrent VTE
• Monitoring: regular assessment of renal function, complete blood counts, and clinical evaluation for bleeding or recurrent thrombosis
• Individualization: dose selection should be based on patient-specific factors, such as age, body weight, and renal function.

From the FDA Drug Label

The recommended dose of apixaban tablets is 10 mg taken orally twice daily for the first 7 days of therapy. After 7 days, the recommended dose is 5 mg taken orally twice daily. The recommended dose of apixaban tablets is 2.5 mg taken orally twice daily after at least 6 months of treatment for DVT or PE

The optimal dose for apixaban to treat extensive pulmonary embolism and deep vein thrombosis indefinitely is 2.5 mg twice daily after at least 6 months of treatment for DVT or PE, and 5 mg twice daily for the first 6 months, with an initial dose of 10 mg twice daily for the first 7 days of therapy 2.

From the Research

Optimal Dose for Apixaban

The optimal dose for apixaban to treat extensive pulmonary embolism and deep vein thrombosis indefinitely is:

• 5 mg twice daily for the treatment dose 3
• 2.5 mg twice daily for the thromboprophylactic dose 3

Efficacy and Safety

Extended anticoagulation with apixaban at either the treatment dose or thromboprophylactic dose reduces the risk of recurrent venous thromboembolism without an increase in the rate of major bleeding 3

• A study found that extended anticoagulation with reduced-dose apixaban (2.5 mg twice daily) was noninferior to full-dose apixaban (5.0 mg twice daily) for the prevention of recurrent venous thromboembolism in patients with active cancer 4
• The reduced dose led to a lower incidence of clinically relevant bleeding complications than the full dose 4

Treatment Duration

Treatment duration should be continued for at least 3 months, and all patients should be assessed for extended duration of therapy based on the precipitating factors that led to the development of the VTE 5

• Extended anticoagulation with apixaban can be considered for patients with a high risk of recurrent VTE 3, 5

Special Populations

There are some populations in which the use of apixaban has not been extensively studied, such as:

• Patients >75 years old 6
• Patients with cancer 6
• Patients with low or high body weight 6
• Patients with poor renal function 6
• Pediatric patients 6
• Patients with a history of heparin-induced thrombocytopenia or identified forms of thrombophilia 6