What is the appropriate dosing of Eliquis (apixaban) for atrial fibrillation in patients with impaired renal function?

From the Guidelines

For patients with atrial fibrillation taking Eliquis (apixaban), the recommended dose is 5 mg twice daily for patients with a creatinine clearance (CrCl) >95 mL/min, but this should be reduced to 2.5 mg twice daily if the patient has a CrCl between 15-30 mL/min or if at least 2 of the following are present: serum creatinine ≥1.5 mg/dL, age ≥80 y, or body weight ≤60 kg, as stated in the 2023 ACC/AHA/ACCP/HRS guideline 1. The dosing of Eliquis in patients with atrial fibrillation and renal impairment is crucial to balance the risk of stroke and bleeding.

• The standard dose of 5 mg twice daily is recommended for patients with a CrCl >95 mL/min, as well as those with a CrCl between 31-50 mL/min and 51-95 mL/min, according to the guideline 1.
• For patients with a CrCl between 15-30 mL/min, the recommended dose is 5 mg or 2.5 mg twice daily, but considering the patient's overall clinical condition, a dose reduction to 2.5 mg twice daily may be necessary to minimize bleeding risk.
• It is essential to note that the guideline recommends a reduced dose of 2.5 mg twice daily if at least two of the following criteria are met: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL, as these factors may increase the risk of bleeding 1.
• Regular monitoring of renal function is vital, especially in elderly patients or those with conditions that might affect kidney function, as declining renal function may necessitate dose adjustments to prevent drug accumulation and reduce bleeding risk while maintaining stroke prevention efficacy.
• Eliquis is partially eliminated by the kidneys, which is why dosage adjustments are needed in renal impairment to balance efficacy and safety, as supported by the guideline 1.

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 renal dosing for atrial fibrillation with Eliquis (apixaban) 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. For other patients, the recommended dose is 5 mg taken orally twice daily 2

From the Research

Atrial Fibrillation and Eliquis (Apixaban) Renal Dosing

• The dosing of apixaban in patients with atrial fibrillation and renal impairment is a critical consideration in clinical practice 3, 4, 5, 6, 7.
• Studies have shown that apixaban is effective and safe in patients with atrial fibrillation and renal dysfunction, with a lower risk of stroke or systemic embolism and major bleeding compared to warfarin 3, 4, 5, 6, 7.
• The pharmacokinetic profile of apixaban is affected by renal function, with higher exposure in patients with advanced chronic kidney disease 5.
• The appropriate dosing of apixaban in patients with renal impairment is crucial, with under-dosing associated with a higher risk of composite outcomes and mortality 6.
• Apixaban at any dose is a reasonable alternative to warfarin in patients with renal impairment, possibly associated with improved outcomes 6.
• Stratified analyses according to initial apixaban dose and baseline estimated glomerular filtration rate have shown that apixaban reduces the risk of stroke or systemic embolism by 37% in those with an eGFR of <30 ml/min/1.73 m2 7.

Key Findings

• Apixaban is associated with a lower risk of stroke or systemic embolism and major bleeding compared to warfarin in patients with atrial fibrillation and renal dysfunction 3, 4, 5, 6, 7.
• The appropriate dosing of apixaban is crucial in patients with renal impairment, with under-dosing associated with a higher risk of composite outcomes and mortality 6.
• Apixaban at any dose is a reasonable alternative to warfarin in patients with renal impairment, possibly associated with improved outcomes 6.

Renal Dosing Considerations

• The dosing of apixaban in patients with atrial fibrillation and renal impairment should be individualized based on renal function and other clinical factors 3, 4, 5, 6, 7.
• Patients with advanced chronic kidney disease may require closer monitoring and adjustment of apixaban dosing to minimize the risk of bleeding and other adverse outcomes 5.