Recommended Dosing of Eliquis (Apixaban) for Pulmonary Embolism
For pulmonary embolism treatment, Eliquis (apixaban) should be administered at 10 mg twice daily for the first 7 days, followed by 5 mg twice daily for at least 3 months. 1, 2
Initial Treatment Phase
- First 7 days: 10 mg twice daily
- After 7 days: 5 mg twice daily for at least 3 months
This dosing regimen is based on the AMPLIFY trial, which demonstrated that apixaban was non-inferior to conventional therapy (enoxaparin/warfarin) for preventing recurrent venous thromboembolism (VTE) while significantly reducing the risk of major bleeding (RR 0.31; 95% CI 0.17-0.55; P < 0.001) 2, 3.
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 2
Dose Adjustments and Special Considerations
- Missed dose: Take as soon as possible on the same day; do not double the dose 1
- Combined P-gp and Strong CYP3A4 Inhibitors: For patients receiving 5 mg or 10 mg twice daily, reduce the dose by 50% when coadministered with drugs that are combined P-gp and strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, ritonavir) 1
- Severe renal impairment: For patients with CrCl <30 ml/min, unfractionated heparin followed by vitamin K antagonists is preferred over apixaban 2
- Surgery or invasive procedures:
- Discontinue apixaban at least 48 hours prior to procedures with moderate/high bleeding risk
- Discontinue at least 24 hours prior to procedures with low bleeding risk 1
Clinical Evidence Supporting This Regimen
The European Society of Cardiology guidelines recommend this dosing regimen based on the AMPLIFY trial, which enrolled 5,395 patients with acute VTE, including 1,836 with PE 4. The trial demonstrated that:
- Apixaban was non-inferior to conventional therapy for preventing recurrent VTE (RR 0.84; 95% CI 0.60-1.18) 4, 3
- Major bleeding occurred significantly less frequently with apixaban compared to conventional therapy (0.6% vs 1.8%, RR 0.31; 95% CI 0.17-0.55; P<0.001) 3
- The composite of major bleeding and clinically relevant non-major bleeding was also significantly reduced with apixaban (4.3% vs 9.7%, RR 0.44; 95% CI 0.36-0.55; P<0.001) 3
Practical Considerations
- Unlike some other anticoagulants, apixaban does not require initial parenteral anticoagulation or overlap therapy 4
- The fixed-dose regimen simplifies treatment compared to warfarin, which requires regular INR monitoring 3
- Apixaban has demonstrated consistent efficacy and safety across various patient populations, including Japanese patients in the AMPLIFY-J study 5
- For patients transitioning from other anticoagulants to apixaban, begin apixaban at the usual time of the next dose of the previous anticoagulant 1
This evidence-based dosing regimen provides effective treatment for pulmonary embolism while minimizing bleeding risk compared to conventional therapy.