Apixaban (Eliquis) Use in Acute Kidney Injury
In acute kidney injury, Eliquis (apixaban) should be used with caution when creatinine clearance falls below 15 mL/min and is generally not recommended in patients with end-stage renal disease on dialysis or with creatinine clearance <15 mL/min. 1
Apixaban Dosing Based on Renal Function
| Renal Function | Recommended Apixaban Use | Dose Adjustment |
|---|---|---|
| Normal/Mild impairment (CrCl >50 mL/min) | Standard dosing | 5 mg twice daily |
| Moderate impairment (CrCl 30-50 mL/min) | Standard dosing* | 5 mg twice daily* |
| Severe impairment (CrCl 15-30 mL/min) | Use with caution | 2.5 mg twice daily** |
| End-stage CKD (CrCl <15 mL/min) | Not recommended | Not recommended |
| Dialysis-dependent | Not recommended | Not recommended |
*Dose reduction to 2.5 mg twice daily if patient meets at least 2 of 3 criteria: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 1, 2
**According to the CHEST guidelines, apixaban 2.5 mg twice daily may be used with caution in severe renal impairment 1
Evidence-Based Recommendations
Moderate Renal Impairment (CrCl 30-59 mL/min)
- Apixaban can be used at standard dosing (5 mg twice daily)
- Dose reduction to 2.5 mg twice daily if patient meets at least 2 of 3 criteria: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 1
Severe Renal Impairment (CrCl 15-30 mL/min)
- The 2018 CHEST guidelines suggest using apixaban 2.5 mg twice daily with caution 1
- American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) guidelines indicate apixaban may be used at 5 mg or 2.5 mg twice daily (with dose reduction criteria) 1
End-Stage Renal Disease (CrCl <15 mL/min)
- Apixaban is generally not recommended in patients with CrCl <15 mL/min 1
- The 2019 AHA/ACC/HRS focused update suggests it might be reasonable to prescribe warfarin or apixaban for oral anticoagulation in these patients 1
Management During Acute Kidney Injury
Monitor renal function closely:
- Evaluate renal function before initiating apixaban and reassess frequently during AKI 1
- Consider more frequent monitoring in patients with fluctuating renal function
Dose adjustment or discontinuation:
- If CrCl falls below 30 mL/min during AKI, consider dose reduction to 2.5 mg twice daily
- If CrCl falls below 15 mL/min, consider discontinuation of apixaban and switching to alternative anticoagulation 1
Alternative anticoagulation options:
Special Considerations
- Apixaban has the lowest renal clearance (27%) among DOACs, making it potentially safer in patients with fluctuating renal function compared to other DOACs 1, 2
- Recent research suggests apixaban may be associated with lower bleeding risk compared to warfarin in patients with severe renal impairment 3, 4, 5, 6
- Drug interactions with P-glycoprotein inhibitors (e.g., amiodarone, verapamil) may increase apixaban plasma concentrations, requiring additional caution in AKI 2
Common Pitfalls and Caveats
Failure to reassess renal function: During AKI, renal function can change rapidly. Regular monitoring is essential.
Inaccurate estimation of renal function: Use the Cockcroft-Gault formula to calculate creatinine clearance rather than eGFR for dosing decisions 1
Overlooking dose reduction criteria: Remember to consider all three criteria (age, weight, serum creatinine) for dose reduction, not just renal function
Assuming all DOACs have similar renal clearance: Apixaban has lower renal clearance (27%) compared to dabigatran (80%), rivaroxaban (33%), and edoxaban (50%) 1
Continuing apixaban in severe AKI: When CrCl falls below 15 mL/min, consider discontinuation and alternative anticoagulation strategies
In summary, while apixaban may be used with caution in patients with moderate to severe renal impairment (CrCl 15-30 mL/min), it should generally be avoided when creatinine clearance falls below 15 mL/min during acute kidney injury.