Apixaban Dosing for 92-Year-Old Patient with Acute PE Weighing 51 kg
For a 92-year-old patient with acute pulmonary embolism weighing 51 kg, the recommended dosing of Eliquis (apixaban) is 10 mg twice daily for the first 7 days, followed by 5 mg twice daily for at least 3 months.
Dosing Rationale
The FDA-approved dosing regimen for apixaban in acute pulmonary embolism consists of:
- Initial phase: 10 mg twice daily for 7 days
- Maintenance phase: 5 mg twice daily 1
This dosing is supported by the 2014 ESC Guidelines which confirm that apixaban should be administered at 10 mg twice daily for 7 days, followed by 5 mg twice daily for treatment of acute VTE 2.
Special Considerations for This Patient
Despite the patient's advanced age (92 years) and low body weight (51 kg), there are important distinctions to note:
No Dose Adjustment for PE Treatment: Unlike atrial fibrillation where dose reduction criteria exist, the FDA label for apixaban does not recommend dose adjustments for age or weight in the treatment of acute PE 1.
Dose Reduction Criteria Do Not Apply: The 2.5 mg twice daily dose reduction (used in atrial fibrillation) is not applicable for the initial treatment of acute PE. This reduced dose is only indicated for extended treatment after at least 6 months of initial PE treatment 1.
Weight Consideration: While the patient weighs 51 kg (which is below 60 kg), this alone is not a criterion for dose reduction in PE treatment, unlike in atrial fibrillation management 2.
Treatment Duration
Treatment should continue for at least 3 months as recommended for PE 2. After the initial 3 months, reassessment for extended therapy should be performed based on:
- Risk of recurrence
- Bleeding risk
- Patient preference
Monitoring Recommendations
For this elderly, low-weight patient:
- Monitor for signs of bleeding complications
- Assess renal function regularly
- Watch for drug interactions that may increase bleeding risk
Potential Pitfalls to Avoid
Incorrect Dose Reduction: A common error is inappropriately applying the atrial fibrillation dose reduction criteria (2.5 mg twice daily) to PE treatment 3.
Premature Discontinuation: Stopping therapy before completing the recommended course increases thrombotic risk 1.
Failure to Transition Properly: If switching from or to other anticoagulants, proper transition protocols should be followed to maintain adequate anticoagulation 1.
Missing the Initial Higher Dose: The 10 mg twice daily loading dose for the first 7 days is crucial for effective initial treatment 2.
Alternative Options
If apixaban is contraindicated or not tolerated:
- Standard therapy with parenteral anticoagulation (LMWH, fondaparinux, or UFH) followed by a vitamin K antagonist
- Other direct oral anticoagulants (rivaroxaban, dabigatran, or edoxaban) with their specific dosing regimens
Clinical trials have demonstrated that apixaban is non-inferior to conventional therapy for PE treatment with potentially lower bleeding risk 2, 4, making it an appropriate choice for this elderly patient.