What are the indications to reduce Eliquis (apixaban)?

From the Guidelines

Eliquis (apixaban) dosage should be reduced from the standard 5mg twice daily to 2.5mg twice daily in patients who meet at least two of the following criteria: age ≥80 years, body weight ≤60kg, or serum creatinine ≥1.5mg/dL, as indicated by the most recent and highest quality study 1.

Indications for Dose Reduction

The following are indications for reducing the dose of Eliquis:

• Age ≥80 years
• Body weight ≤60kg
• Serum creatinine ≥1.5mg/dL
• Severe renal impairment (creatinine clearance 15-29 mL/min)

Special Considerations

• For patients receiving Eliquis for DVT/PE treatment, after completing 6 months of treatment at 5mg twice daily, the dose may be reduced to 2.5mg twice daily for continued prevention.
• When Eliquis is used with strong dual inhibitors of CYP3A4 and P-gp (like ketoconazole, itraconazole, ritonavir, or clarithromycin), the dose should be reduced by 50%.
• Patients with end-stage renal disease on dialysis should receive the reduced dose regardless of other factors.

Rationale

These dose reductions are necessary because Eliquis is primarily metabolized by the liver and eliminated through the kidneys, so factors affecting these organs or drug metabolism pathways can increase blood levels and bleeding risk. Always consult with a healthcare provider before making any changes to Eliquis dosing, as recommended by 1 and 1.

Supporting Evidence

The recommendations are based on the latest guidelines and studies, including the 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation 1 and the 2020 ACC expert consensus decision pathway for anticoagulant and antiplatelet therapy in patients with atrial fibrillation or venous thromboembolism undergoing percutaneous coronary intervention or with atherosclerotic cardiovascular disease 1.

From the Research

Indications to Reduce Eliquis

The following are indications to reduce Eliquis (apixaban) dosage:

• Age ≥80 years 2
• Body weight ≤60 kg 2
• Serum creatinine ≥1.5 mg/dL 2
• Patients with end-stage kidney disease (ESKD) on dialysis, where a lower dose of apixaban may be associated with a lower risk of bleeding compared to warfarin 3
• Cancer patients, where low-dose apixaban (2.5 mg twice daily) may be effective and safe as secondary prophylaxis for venous thromboembolism (VTE) after initial 6 months of full-dose treatment 4

Special Populations

In certain populations, the use of apixaban has not been extensively studied, and dose reduction may be considered:

• Patients >75 years old 5
• Patients with cancer 5, 4
• Patients with low or high body weight 5
• Patients with poor renal function 5, 3
• Pediatric patients 5
• Patients with a history of heparin-induced thrombocytopenia or identified forms of thrombophilia 5