Recommended Dose of Apixaban (Eliquis) for Pulmonary Embolism Treatment
The recommended dose of apixaban for pulmonary embolism treatment is 10 mg twice daily for the first 7 days, followed by 5 mg twice daily for at least 3 months. 1
Initial Treatment Phase
- First 7 days: 10 mg orally twice daily
- After 7 days: 5 mg orally twice daily
- Minimum treatment duration: 3 months
This dosing regimen has been extensively studied in clinical trials and has demonstrated both efficacy and safety in the treatment of pulmonary embolism.
Evidence Supporting This Recommendation
The European Society of Cardiology (ESC) guidelines clearly recommend this dosing regimen based on the AMPLIFY trial, which enrolled 5,395 patients with acute VTE, including 1,836 with pulmonary embolism 1. In this study, apixaban was non-inferior to conventional therapy (enoxaparin/warfarin) for preventing recurrent VTE, with significantly less major bleeding (RR 0.31; 95% CI 0.17–0.55; P < 0.001) 1.
The FDA-approved labeling for apixaban confirms this dosing schedule, stating: "The recommended dose of apixaban tablets is 10 mg taken orally twice daily for the first 7 days of therapy. After 7 days, the recommended dose is 5 mg taken orally twice daily." 2
Duration of Treatment
The duration of anticoagulation should be determined based on risk factors:
- First episode with major transient/reversible risk factor: 3 months
- Unprovoked PE or ongoing risk factors: Extended anticoagulation (>3 months)
- Recurrent VTE: Indefinite anticoagulation
Special Considerations
Dose Reduction
- No dose reduction is required for PE treatment based on age, weight, or renal function alone
- However, for patients taking combined P-glycoprotein (P-gp) and strong CYP3A4 inhibitors (e.g., ketoconazole, ritonavir), reduce the dose by 50% 2
Renal Impairment
- For severe renal impairment (CrCl <30 ml/min), unfractionated heparin followed by vitamin K antagonists is preferred over apixaban 3
Cancer Patients
- Apixaban has demonstrated non-inferiority to dalteparin for cancer-associated VTE without increased risk of major bleeding (hazard ratio 0.82; 95% CI 0.40-1.69) 4
- Traditional recommendation has been LMWH for cancer patients, but recent evidence supports apixaban as a viable alternative
Clinical Benefits of Apixaban
Compared to conventional therapy with enoxaparin/warfarin, apixaban offers:
- Similar efficacy: Non-inferior for preventing recurrent VTE 1, 5
- Improved safety: Significantly lower rates of major bleeding (0.6% vs 1.8%) 5
- Reduced hospitalization: Extended treatment with apixaban significantly reduces hospitalization rates compared to placebo (HR 0.64; 95% CI 0.43-0.95 for 2.5mg dose) 6
- Convenience: Fixed dosing without need for routine monitoring
Practical Administration Tips
- If a dose is missed, take it as soon as possible on the same day and resume twice-daily administration
- Do not double the dose to make up for a missed dose
- For patients unable to swallow tablets, apixaban tablets may be crushed and suspended in water or apple juice, or mixed with applesauce 2
- Discontinue apixaban at least 48 hours prior to elective surgery with moderate/high bleeding risk 2
Common Pitfalls to Avoid
- Inadequate initial dosing: Failing to use the higher 10 mg twice daily dose for the first 7 days
- Premature discontinuation: Stopping therapy before completing at least 3 months of treatment
- Missing the transition: Forgetting to switch from 10 mg twice daily to 5 mg twice daily after 7 days
- Drug interactions: Not accounting for medications that affect P-gp and CYP3A4 pathways
- Neuraxial anesthesia: Not allowing adequate time between apixaban discontinuation and spinal/epidural procedures
Apixaban has consistently demonstrated a favorable safety and efficacy profile in real-world studies, with lower risks of bleeding and recurrent VTE compared to warfarin across various time points and patient subgroups 7.