What is the recommended dose of Eliquis (apixaban) for patients with non-valvular atrial fibrillation?

Apixaban Dosing for Non-Valvular Atrial Fibrillation

The standard recommended dose of apixaban (Eliquis) for patients with non-valvular atrial fibrillation is 5 mg taken orally twice daily, with a reduced dose of 2.5 mg twice daily for patients with at least two of the following characteristics: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1

Standard Dosing Protocol

The dosing recommendation is based on high-quality evidence from clinical trials and FDA-approved labeling:

• Standard dose: 5 mg twice daily for most patients with non-valvular AF 2, 1
• Reduced dose: 2.5 mg twice daily for patients with ≥2 of these risk factors 2, 1:
  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL

Efficacy and Safety Profile

Apixaban has demonstrated superior efficacy and safety compared to warfarin in the ARISTOTLE trial:

• 21% relative risk reduction in stroke or systemic embolism (HR 0.79; 95% CI, 0.66-0.95) 2
• 31% reduction in major bleeding (HR 0.69; 95% CI, 0.60-0.80) 2
• 11% reduction in all-cause mortality (HR 0.89; 95% CI, 0.80-0.998) 2

Renal Function Considerations

• Apixaban can be used across a wide range of renal function
• No dose adjustment needed for mild to moderate renal impairment alone
• For severe renal impairment (CrCl 15-29 mL/min), use standard dosing criteria (5 mg BID or 2.5 mg BID based on age, weight, and creatinine) 1
• Apixaban should not be used if CrCl <15 mL/min or in patients on dialysis unless other criteria for dose reduction are met 1

Common Pitfalls in Apixaban Dosing

1. Inappropriate underdosing: Studies show 34-40% of patients are inappropriately underdosed 3, 4, which may reduce stroke prevention efficacy without improving safety.

2. Failure to reduce dose when indicated: About 19% of patients who should receive the reduced 2.5 mg twice daily dose are prescribed the standard 5 mg twice daily dose 4, potentially increasing bleeding risk.

3. Misinterpreting dose reduction criteria: Remember that at least TWO of the three criteria (age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL) must be present to warrant dose reduction.

4. Medication adherence challenges: Adherence rates for apixaban (78%) are slightly lower than for rivaroxaban (81.8%) at 6 months 5, which may impact effectiveness.

Monitoring and Follow-up

• No routine coagulation monitoring is required
• Regular assessment of renal function is recommended
• Evaluate for bleeding complications at follow-up visits
• Apixaban should be discontinued at least 48 hours prior to elective surgery with moderate/high bleeding risk, and 24 hours prior to procedures with low bleeding risk 1

Special Considerations

• Avoid concomitant use with other anticoagulants, strong dual inhibitors of CYP3A4 and P-gp
• If anticoagulation must be temporarily discontinued, restart as soon as medically appropriate to reduce thrombotic risk 1
• Premature discontinuation increases thrombotic risk; consider bridging with another anticoagulant if apixaban must be stopped 1

By following these evidence-based dosing recommendations, clinicians can optimize the balance between stroke prevention and bleeding risk in patients with non-valvular atrial fibrillation.