Recommended Dose of Apixaban for Atrial Fibrillation
The standard recommended dose of apixaban for most patients with atrial fibrillation is 5 mg taken orally twice daily, with a reduced dose of 2.5 mg twice daily for patients who have at least two of the following characteristics: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1, 2
Dosing Algorithm
Standard Dose (5 mg twice daily):
- For most patients with nonvalvular atrial fibrillation
- Appropriate across all creatinine clearance levels, including those with CrCl >15 mL/min
- Remains effective even in patients with a single dose-reduction criterion 3
Reduced Dose (2.5 mg twice daily):
Required when patient has at least TWO of:
- Age ≥80 years
- Body weight ≤60 kg
- Serum creatinine ≥1.5 mg/dL
Renal Considerations
- Unlike other DOACs, apixaban can be used across the spectrum of renal function, including patients with severe renal impairment
- Apixaban is the only DOAC that maintains the same dosing recommendation for patients with CrCl <15 mL/min or on dialysis 1
- No dose adjustment required based solely on renal function unless combined with other criteria
Important Clinical Considerations
Inappropriate Dose Reduction
- Studies show frequent inappropriate dose reduction in clinical practice, with up to 60.8% of patients receiving reduced doses without meeting criteria 4
- Underdosing may compromise stroke prevention efficacy
- Age, weight, and serum creatinine are independently associated with inappropriate dose reduction, but should only trigger dose reduction when at least two factors are present
Perioperative Management
For patients requiring surgery or invasive procedures:
- Low bleeding risk procedures: Discontinue apixaban 24 hours before (1 full day)
- High bleeding risk procedures: Discontinue apixaban 48 hours before (2 full days) 1
- Resume once adequate hemostasis is established
Efficacy and Safety Profile
- Apixaban demonstrated superior stroke prevention compared to warfarin (HR 0.79; 95% CI, 0.66-0.95) 1
- Lower risk of major bleeding compared to warfarin (HR 0.69; 95% CI, 0.60-0.80) 1
- Particularly favorable gastrointestinal bleeding profile compared to other DOACs 1
Common Pitfalls to Avoid
- Inappropriate dose reduction based on a single criterion (age, weight, or renal function alone)
- Failure to reduce dose when two or more criteria are met
- Discontinuing without bridging for high-risk procedures too close to the procedure
- Confusing apixaban dosing with other DOACs that require adjustment based solely on renal function
Remember that the 5 mg twice daily dose remains safe and efficacious for patients with only one dose-reduction criterion, and dose reduction should only occur when at least two criteria are present 3.