When should the dosage of Eliquis (apixaban) be decreased?

When to Decrease Dosage of Eliquis (Apixaban)

The dosage of Eliquis (apixaban) should be decreased to 2.5 mg twice daily when a patient meets at least two of the following three characteristics: age ≥80 years, body weight ≤60 kg, and/or serum creatinine ≥1.5 mg/dL. 1, 2, 3

Primary Dose Reduction Criteria

The standard dose of apixaban for most patients is 5 mg taken orally twice daily. However, dose reduction is necessary in specific circumstances:

Required Dose Reduction (2.5 mg twice daily)

• When patient meets at least 2 of these 3 criteria:
  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL 1, 2, 3

Renal Function Considerations

• For patients with severe renal impairment (CrCl 15-29 mL/min), the reduced dose of 2.5 mg twice daily is recommended 2
• No dose adjustment is needed for mild to moderate renal impairment alone 2
• For patients with end-stage kidney disease (ESKD) on hemodialysis, the FDA label suggests no dosing adjustment unless they have additional dose reduction characteristics 1

Drug Interactions Requiring Dose Reduction

• For patients receiving apixaban 5 mg twice daily, reduce the dose by 50% (to 2.5 mg twice daily) when co-administered with combined P-glycoprotein (P-gp) and strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, ritonavir) 3
• For patients already taking 2.5 mg twice daily, avoid co-administration with combined P-gp and strong CYP3A4 inhibitors altogether 3

Perioperative Considerations

Temporary discontinuation rather than dose reduction is recommended before procedures:

• Stop apixaban at least 48 hours prior to elective surgery or procedures with moderate/high bleeding risk 3
• Stop apixaban at least 24 hours prior to procedures with low bleeding risk 3
• Resume apixaban as soon as adequate hemostasis is established 2, 3

Common Pitfalls in Apixaban Dosing

1. Inappropriate underdosing: Studies show that underdosing is the most common prescribing error with apixaban (4.7% to 26.1% of patients) 1. This is particularly problematic when only one dose-reduction criterion is present but the reduced dose is given anyway.

2. Misapplication of criteria: The dose reduction requires at least TWO criteria to be present. Patients with only ONE criterion should receive the standard 5 mg twice daily dose 4. Research shows that patients with only one dose-reduction criterion still benefit from the standard 5 mg twice daily dose compared to warfarin 4.

3. Inappropriate dose reduction due to perceived bleeding risk: Many clinicians inappropriately reduce the dose due to perceived bleeding risk, history of minor bleeding, or concurrent antiplatelet therapy 1. These are not FDA-approved criteria for dose reduction.

4. Continuing home dose without reassessment: Blindly continuing a home dose without reassessing the appropriate criteria is a common error 1.

5. Overdosing in patients with multiple criteria: Failing to reduce the dose when two or more criteria are present increases bleeding risk 1, 2.

By adhering to these evidence-based guidelines for apixaban dosing, clinicians can optimize the balance between preventing thromboembolic events and minimizing bleeding risk in patients requiring anticoagulation.