What is the Apixaban (apixaban) dose for Venous Thromboembolism (VTE) based on Glomerular Filtration Rate (GFR) in patients with Impaired Renal Function?

From the Guidelines

For patients with venous thromboembolism (VTE) and a glomerular filtration rate (GFR) of 30-59 ml/min, the recommended dose of apixaban is 5.0 or 2.5 mg twice daily, as per the guidelines outlined in the Journal of the American College of Cardiology 1. When considering the dose of apixaban for VTE treatment based on GFR, it's essential to note that the guidelines provide specific recommendations for different levels of renal impairment.

• For patients with a GFR of 30-59 ml/min, the dose is 5.0 or 2.5 mg twice daily, as recommended by the AHA/ACC/HRS guidelines (2019) and other guidelines 1.
• For patients with a GFR of 15-29 ml/min, the dose is also 5.0 or 2.5 mg twice daily, although some guidelines suggest considering a lower dose or alternative anticoagulation therapy 1.
• For patients with a GFR less than 15 ml/min or those on dialysis, the use of apixaban is generally not recommended due to limited clinical data, although some guidelines suggest considering a dose of 2.5 mg twice daily 1. It's also important to consider other patient characteristics, such as age, weight, and serum creatinine levels, when determining the appropriate dose of apixaban, as recommended by regulatory authorities and clinical guidelines 1.
• For example, the use of apixaban 2.5 mg twice daily is recommended if any two of the following patient characteristics are present: serum creatinine greater than 1.5 mg/dl, age greater than 80 years, or body weight less than 60 kg 1. In addition to the guidelines, a more recent study published in 2021 provides further guidance on the dosing of apixaban for VTE treatment, recommending a standard dose of 10 mg twice daily for the first 7 days, followed by 5 mg twice daily thereafter, regardless of renal function for most patients with GFR above 15 mL/min 1. However, this study does not provide specific guidance on dosing for patients with severe renal impairment, and therefore, the guidelines outlined in the Journal of the American College of Cardiology should be followed 1.

From the Research

Apixaban Dosing for VTE Based on GFR

• The dosing of apixaban for venous thromboembolism (VTE) in patients with varying degrees of renal impairment is a critical consideration in clinical practice.
• Studies have investigated the safety and efficacy of apixaban compared to traditional anticoagulants like warfarin in patients with severe renal impairment, including those with estimated glomerular filtration rate (eGFR) <30 mL/min/m2 or on dialysis 2, 3.
• A systematic review and meta-analysis found that apixaban was associated with a significant reduction in VTE recurrence and major bleeding compared to warfarin in patients with severe renal failure 2.
• A multicenter study found no significant difference in time to composite bleeding events or recurrent VTE between apixaban and warfarin in patients with severe renal impairment, although apixaban was associated with a reduced incidence of anticoagulation-related emergency department admissions 3.
• Other studies have evaluated the effectiveness and safety of apixaban in patients with VTE and active cancer, as well as those with risk factors for bleeding or recurrences, and found apixaban to be associated with a lower risk of recurrent VTE and bleeding compared to warfarin 4, 5.
• A retrospective cohort analysis found that apixaban was associated with a significantly lower risk of recurrent VTE, major bleeding, and clinically relevant non-major bleeding compared to warfarin in VTE patients with chronic kidney disease, including those with stage V/end-stage renal disease (ESRD) 6.

Key Findings

• Apixaban is generally considered safe and effective for the treatment of VTE in patients with severe renal impairment, although the dosing should be adjusted according to the patient's renal function.
• The studies suggest that apixaban may be associated with a lower risk of recurrent VTE and bleeding compared to warfarin in patients with severe renal impairment, although the results are not uniform across all studies.
• The dosing of apixaban in patients with renal impairment should be individualized based on the patient's specific clinical characteristics and renal function.

Renal Impairment Considerations

• Patients with severe renal impairment (eGFR <30 mL/min/m2) may require dose adjustments when using apixaban for VTE treatment.
• The studies suggest that apixaban may be a viable option for VTE treatment in patients with severe renal impairment, including those on dialysis, although close monitoring of renal function and bleeding risk is necessary 2, 3.