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

Recommended Apixaban Dosing for Non-valvular Atrial Fibrillation

For patients with non-valvular atrial fibrillation, the recommended dose of Eliquis (apixaban) 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: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1, 2

Standard Dosing Protocol

• Standard dose: 5 mg twice daily for most patients with non-valvular AFib 2
• Reduced dose: 2.5 mg twice daily when at least two of these criteria are met:
  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL 1, 2

Special Populations

Renal Considerations

• Severe renal impairment (CrCl 15-29 mL/min): 2.5 mg twice daily 1
• Mild to moderate renal impairment alone: No dose adjustment needed 1
• End-stage renal disease on hemodialysis: 5 mg twice daily, reduced to 2.5 mg twice daily if age ≥80 years or body weight ≤60 kg 1

Clinical Efficacy and Safety

Apixaban has demonstrated significant benefits over warfarin in patients with non-valvular AFib:

• 21% reduction in stroke or systemic embolism (HR 0.79; 95% CI, 0.66-0.95) 1
• 11% reduction in all-cause mortality (HR 0.89; 95% CI, 0.80-0.99) 1
• 31% reduction in major bleeding (HR 0.69; 95% CI, 0.60-0.80) 1
• 49% reduction in hemorrhagic stroke 1
• 52% reduction in intracranial hemorrhage 1

Common Pitfalls in Apixaban Prescribing

Underdosing

Studies have identified significant rates of inappropriate dosing in clinical practice:

• Up to 34-39% of patients may receive underdosed apixaban, particularly elderly patients 3, 4
• Most common in patients meeting only one dose reduction criterion, especially age ≥80 years 5, 6

Overdosing

• Less common than underdosing (approximately 0.7-5% of prescriptions) 5, 3
• Can increase bleeding risk unnecessarily

Factors Associated with Inappropriate Dosing

• Age, weight, and serum creatinine levels are independently associated with inappropriate underdosing 6
• Concomitant antidepressant use may increase likelihood of underdosing 3
• Initial management in neurology departments is associated with more appropriate dosing 3

Temporary Interruption for Procedures

• For low bleeding risk procedures: Interrupt apixaban for 24 hours before the procedure 1, 2
• For high bleeding risk procedures: Interrupt apixaban for 48 hours before the procedure 1, 2
• Resume apixaban at least 6 hours after the procedure if adequate hemostasis is achieved 1

Missed Dose Management

If a dose is missed:

• Take the missed dose as soon as possible on the same day 2
• Resume twice-daily administration schedule 2
• Do not double the dose to make up for a missed dose 2

Monitoring Considerations

• Regular assessment for bleeding signs 1
• Periodic renal function monitoring, especially in elderly patients 1
• Strict adherence to dosing schedule is essential due to short half-life (approximately 12 hours) 1, 7

Following these evidence-based dosing recommendations will optimize stroke prevention while minimizing bleeding risk in patients with non-valvular atrial fibrillation requiring anticoagulation.