What is the recommended dosing for apixaban (Eliquis) in the treatment of Deep Vein Thrombosis (DVT)?

Apixaban (Eliquis) Dosing for Deep Vein Thrombosis (DVT)

For DVT treatment, apixaban (Eliquis) should be administered at 10 mg orally twice daily for the first 7 days, followed by 5 mg orally twice daily for at least 3 months. 1

Initial Treatment Phase

The FDA-approved dosing regimen for apixaban in DVT treatment consists of two phases:

1. Acute phase (first 7 days):

   • 10 mg taken orally twice daily

2. Maintenance phase (after first 7 days):

   • 5 mg taken orally twice daily
   • Continue for at least 3 months (duration depends on risk factors)

This dosing regimen was established in the AMPLIFY trial, which demonstrated that apixaban was noninferior to conventional therapy (enoxaparin/warfarin) for preventing recurrent VTE while having a significantly lower risk of major bleeding (0.6% vs 1.8%). 2, 3

Extended Treatment Phase

For patients requiring extended anticoagulation beyond the initial treatment period:

• After at least 6 months of treatment at standard doses, the dose may be reduced to 2.5 mg orally twice daily for secondary prevention of DVT 2, 1

Special Considerations

Renal Function

• Apixaban should be avoided in patients with severe renal impairment (CrCl <15 mL/min)
• Patients with CrCl <25 mL/min were excluded from clinical trials 2

Hepatic Function

• Avoid in patients with hepatic impairment (transaminases >2× upper limit of normal or total bilirubin >1.5× upper limit of normal) 2

Drug Interactions

• For patients receiving apixaban 5 mg or 10 mg twice daily who require concomitant therapy with combined P-gp and strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, ritonavir):
  • Reduce the dose by 50% 1

Missed Doses

• If a dose is missed, take it as soon as possible on the same day
• Resume twice-daily administration schedule
• Do not double the dose to make up for a missed dose 1

Perioperative Management

• Discontinue apixaban at least 48 hours prior to elective surgery with moderate/high bleeding risk
• Discontinue at least 24 hours prior to procedures with low bleeding risk
• Restart after adequate hemostasis is established 1

Duration of Therapy

Duration depends on whether the DVT was provoked or unprovoked and the patient's bleeding risk:

• Provoked DVT (transient risk factor): Minimum 3 months
• Unprovoked DVT: Consider extended therapy (beyond 3 months) in patients with low-to-moderate bleeding risk 2
• Cancer-associated DVT: Extended therapy recommended (at least 6 months) 2

Important Caveats

1. While apixaban has demonstrated efficacy in general DVT treatment, some guidelines note limited data specifically in cancer patients 2

2. The fixed-dose regimen of apixaban eliminates the need for routine coagulation monitoring, which is an advantage over warfarin therapy 3

3. Missing doses can significantly impact efficacy, so patient adherence to the twice-daily regimen is crucial

4. If transitioning from warfarin to apixaban, start apixaban when INR is below 2.0 1

By following this dosing regimen, apixaban provides effective treatment for DVT with a favorable safety profile compared to traditional anticoagulation approaches.