From the Guidelines
Apixaban should be started at a dose of 10 mg orally twice daily for the first 7 days of therapy, followed by 5 mg orally twice daily, as recommended for the initial treatment of VTE 1. This dosing regimen is based on the most recent and highest quality study available, which prioritizes morbidity, mortality, and quality of life as the outcome.
Key Considerations
- The initial dose of 10 mg orally twice daily for the first 7 days is crucial for effective anticoagulation in the treatment of VTE.
- After the first 7 days, the dose can be reduced to 5 mg orally twice daily for continued anticoagulation.
- It is essential to note that dose adjustments may be necessary for patients with specific criteria, such as age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL, as recommended in other studies 1.
Additional Recommendations
- Patients should be counseled to take the medication at approximately the same times each day and not to skip doses, as consistent blood levels are important for effective anticoagulation.
- Food does not significantly affect absorption, so apixaban can be taken with or without food.
- The rapid onset of action (reaching peak levels within 3-4 hours) makes apixaban effective shortly after the first dose, providing an advantage over other anticoagulants.
From the FDA Drug Label
2.1 Recommended Dose Reduction of Risk of Stroke and Systemic Embolism in Patients with Nonvalvular Atrial Fibrillation 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 starting dose of apixaban for most patients is 5 mg taken orally twice daily. However, for patients with certain characteristics, such as age ≥ 80 years, body weight ≤ 60 kg, or serum creatinine ≥ 1.5 mg/dL, the recommended dose is 2.5 mg twice daily.
- Indications for apixaban include reduction of risk of stroke and systemic embolism in nonvalvular atrial fibrillation, prophylaxis of deep vein thrombosis following hip or knee replacement surgery, treatment of deep vein thrombosis and pulmonary embolism, and reduction in the risk of recurrence of DVT and PE. 2
From the Research
Dosing for Starting Apixaban
- The standard dose of apixaban is 5 mg twice daily, but dose reduction is recommended based on patient age, weight, and renal function 3.
- Factors associated with inappropriate dose reduction are age, patient weight, and serum creatinine level, which are the same factors used as criteria for dose adjustment 3.
- Patients with atrial fibrillation and isolated advanced age, low body weight, or renal dysfunction have a higher risk of stroke or systemic embolism and major bleeding, but show consistent benefits with the 5 mg twice daily dose of apixaban vs warfarin compared with patients without these characteristics 4.
- The 5 mg twice daily dose of apixaban is safe, efficacious, and appropriate for patients with only 1 dose-reduction criterion 4.
Special Considerations
- In patients with venous thromboembolism, coagulation markers may differ in patients prescribed higher doses of apixaban, and a dose adjustment criterion may be warranted in such patients 5.
- Apixaban dose adjustment to 2.5 mg twice daily versus warfarin was consistent for coagulation biomarkers and clinical outcomes, providing reassuring data on efficacy and safety 6.
Comparison with Other Anticoagulants
- Treatment with rivaroxaban compared with apixaban was associated with a significantly increased risk of major ischemic or hemorrhagic events in patients with atrial fibrillation 7.
- The risk of major ischemic or hemorrhagic events was increased for rivaroxaban in both those receiving the reduced dose and the standard dose groups 7.