What is the appropriate dosing of Eliquis (apixaban) for stroke prevention in a patient with atrial fibrillation after an embolic stroke?

From the Guidelines

For stroke prevention in a patient with atrial fibrillation after an embolic stroke, the standard Eliquis (apixaban) dosing is 5 mg taken orally twice daily, but the dose should be reduced to 2.5 mg twice daily if the patient meets at least two of the following criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL, as recommended by the 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation 1.

Key Considerations

• The dose reduction is crucial for patients with severe renal impairment (creatinine clearance 15-29 mL/min) to minimize the risk of bleeding complications.
• Eliquis should be taken consistently at approximately 12-hour intervals with or without food.
• After an embolic stroke, anticoagulation is typically initiated once neuroimaging has confirmed no hemorrhagic transformation, usually within 4-14 days depending on stroke severity and size.
• Regular monitoring of renal function is recommended, but routine coagulation monitoring is not required, as the anticoagulant effect of apixaban is predictable and stable 1.

Patient Education

• Patients should be educated on the importance of adherence to the prescribed dosing regimen and the potential risks of missed doses or prolonged interruptions of therapy.
• They should also be informed about the signs and symptoms of bleeding complications and the need to seek immediate medical attention if they occur.

Clinical Context

• The use of apixaban in patients with atrial fibrillation has been shown to be effective in reducing the risk of stroke and systemic embolism, with a favorable safety profile compared to warfarin 1.
• However, the decision to initiate anticoagulation therapy should be individualized, taking into account the patient's risk factors, renal function, and other comorbidities.

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 appropriate dosing of Eliquis (apixaban) for stroke prevention in a patient with atrial fibrillation after an embolic stroke is 5 mg taken orally twice daily for most patients. However, a reduced dose of 2.5 mg twice daily may be considered if the patient has 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 2

From the Research

Dosing of Eliquis (Apixaban) for Stroke Prevention

The appropriate dosing of Eliquis (apixaban) for stroke prevention in a patient with atrial fibrillation after an embolic stroke is as follows:

• The standard dose of apixaban is 5 mg twice daily 3
• However, for patients with severe renal impairment (creatinine clearance 25 to 30 mL/min), the dose may need to be reduced to 2.5 mg twice daily 4
• Patients with stage III chronic kidney disease (CKD) may also require a reduced dose of 2.5 mg twice daily 5

Considerations for Patients with Renal Impairment

• Apixaban is partially renally excreted and may accumulate in patients with renal impairment 5
• Patients with advanced chronic kidney disease have a higher burden of atrial fibrillation and may require closer monitoring 4
• The pharmacokinetic profile of apixaban is affected by renal impairment, with higher exposure in patients with creatinine clearance 25 to 30 mL/min 4

Efficacy and Safety of Apixaban

• Apixaban has been shown to be effective in reducing the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation 3
• Apixaban has also been shown to be safe and effective in patients with renal impairment, with a lower risk of major bleeding compared to warfarin 4
• The safety and efficacy of apixaban in patients with advanced chronic kidney disease, including those receiving dialysis, require further study 4