Is a reduced dose of Eliquis (apixaban) 2.5mg twice daily (BID) appropriate for an 87-year-old patient with Paroxysmal Atrial Fibrillation (PAF) and a CHA2DS2-VASc score of 5, Impaired Renal Function (GFR 44), and serum Creatinine (Cr) level of 1.2, compared to the current dose of Eliquis (apixaban) 5mg BID?

From the Guidelines

I would recommend maintaining the patient on Eliquis 5mg BID rather than reducing to 2.5mg BID. The standard dose of Eliquis (apixaban) for stroke prevention in atrial fibrillation is 5mg twice daily. Dose reduction to 2.5mg twice daily is only indicated when a patient meets at least two of the following criteria: age ≥80 years, body weight ≤60kg, or serum creatinine ≥1.5mg/dL. While this patient is 87 years old (meeting one criterion), the creatinine of 1.2 does not meet the threshold for dose reduction, and we don't have information about weight.

Key Considerations

• The patient's CHA2DS2-VASc score of 5 indicates a high stroke risk, which warrants full anticoagulation.
• The GFR of 44 does not necessitate dose reduction, as Eliquis can be used at full dose with GFR >25, as per the guidelines from the American Heart Association Task Force/American College of Cardiology/Heart Rhythm Society 1.
• Without recent falls or other bleeding concerns, the benefit of stroke prevention with the standard dose likely outweighs bleeding risks.

Guideline Recommendations

• The 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation recommends reevaluation of the need for and choice of anticoagulant therapy at periodic intervals to reassess stroke and bleeding risks 1.
• The guideline also recommends that for patients with AF (except with moderate-to-severe mitral stenosis or a mechanical heart valve) who are unable to maintain a therapeutic INR level with warfarin, use of a NOAC is recommended.

Patient-Specific Factors

• The patient's age and GFR do not meet the criteria for dose reduction, and there are no other mentioned concerns that would warrant a reduction in dose.
• The patient's high CHA2DS2-VASc score indicates a high risk of stroke, making full anticoagulation the preferred treatment option. I would suggest discussing with the PCP to understand if there are other specific concerns not mentioned that prompted the dose reduction recommendation.

From the FDA Drug Label

The recommended dose of apixaban tablets for most patients is 5 mg taken orally twice daily. The recommended dose of apixaban tablets is 2.5 mg twice daily in patients with at least two of the following characteristics: • age greater than or equal to 80 years • body weight less than or equal to 60 kg • serum creatinine greater than or equal to 1.5 mg/dL

The patient is 87 years old and has a serum creatinine of 1.2 mg/dL, which is less than 1.5 mg/dL. However, since the patient's age is greater than 80 years, they meet one of the criteria for the reduced dose.

• Age: 87 years (meets the criteria)
• Body weight: Not provided
• Serum creatinine: 1.2 mg/dL (does not meet the criteria) Considering the patient's age and the fact that they have a GFR of 44, which indicates renal impairment, but not severe enough to meet the criteria for the reduced dose based on serum creatinine, the decision to reduce the dose to 2.5mg BID should be based on individual assessment of the patient's risk factors. Given the patient's CHA2DS2-vasc score of 5, which indicates a high risk of stroke, the benefits of anticoagulation should be carefully weighed against the risks of bleeding. Since the patient meets only one of the criteria for the reduced dose, the decision to reduce the dose should be made with caution, taking into account the patient's overall clinical profile, including their renal function and risk of bleeding. It is agreeable to consider a lower dose of Eliquis, but this decision should be made on a case-by-case basis, considering the individual patient's risk factors and clinical characteristics 2.

From the Research

Patient Profile

• Age: 87
• Latest GFR: 44
• Cr: 1.2
• History: PAF with CHA2DS2-vasc-5
• Current medication: Eliquis 5mg BID
• Proposed change: Eliquis 2.5mg BID

Rationale for Dose Reduction

• The patient's age and renal function (GFR 44) may be contributing factors to the proposed dose reduction 3
• However, there is no clear evidence to suggest that a dose reduction is necessary based solely on age and renal function 4, 5

Efficacy and Safety of Reduced-Dose Apixaban

• Studies have shown that reduced-dose apixaban (2.5mg BID) may be associated with higher rates of thromboembolic events and major bleeding compared to the standard dose (5mg BID) 5, 6
• However, other studies have found that the benefits of apixaban compared to warfarin are similar across different levels of renal function and age 3, 4

Considerations for Dose Reduction

• The patient's CHA2DS2-vasc score of 5 indicates a high risk of stroke, which may be a consideration when deciding on a dose reduction 6
• The patient's renal function (GFR 44) is an important factor to consider when determining the appropriate dose of apixaban 3, 7
• There is no evidence to suggest that the patient has experienced any adverse effects or bleeding events while taking the standard dose of Eliquis, which may be a consideration when deciding on a dose reduction 5, 6