What is the recommended dosage of Eloquis (apixaban) for patients with non-valvular atrial fibrillation (Afib)?

Recommended Dosage of Apixaban for Non-valvular Atrial Fibrillation

The standard recommended dose of apixaban (Eliquis) for most patients with non-valvular atrial fibrillation is 5 mg taken orally twice daily, with a reduced dose of 2.5 mg twice daily required for patients who have at least two of the following characteristics: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1, 2, 3

Dosing Algorithm

1. Standard Dosing:

   • 5 mg twice daily for most patients with non-valvular atrial fibrillation 1

2. Dose Reduction Criteria (reduce to 2.5 mg twice daily if patient has at least 2 of):

   • Age ≥80 years
   • Body weight ≤60 kg
   • Serum creatinine ≥1.5 mg/dL 1, 3

3. Special Populations:

   • Patients with severe renal impairment (CrCl 15-29 mL/min): 2.5 mg twice daily 3
   • Patients with end-stage renal disease on hemodialysis: 2.5 mg twice daily if age ≥80 years or body weight ≤60 kg 3

Clinical Evidence and Benefits

Apixaban has demonstrated significant benefits compared to warfarin in patients with non-valvular atrial fibrillation:

• 21% reduction in stroke or systemic embolism 2, 3
• 31% reduction in major bleeding 2, 3
• 11% reduction in all-cause mortality 2, 3
• 49% reduction in hemorrhagic stroke 3
• 52% reduction in intracranial hemorrhage 3

The ARISTOTLE trial demonstrated that the standard 5 mg twice daily dose of apixaban is safe and efficacious for patients with only one dose-reduction criterion, showing consistent benefits compared to warfarin 4.

Common Prescribing Errors and Pitfalls

• Underdosing: Studies show that approximately 34-39% of apixaban prescriptions, particularly in elderly patients, may be underdosed 5, 6. This is often due to physicians prescribing the reduced dose based on only one criterion rather than the required two criteria.

• Overdosing: Less common but still concerning, about 5% of prescriptions may involve overdosing 5.

• Medication Adherence: Missing doses is particularly problematic due to apixaban's short half-life (9-14 hours), potentially leaving patients unprotected 2, 3.

Temporary Interruption for Procedures

• For low bleeding risk procedures: interrupt apixaban for 24 hours before the procedure 3, 1
• For high bleeding risk procedures: interrupt apixaban for 48-72 hours before the procedure 3, 1
• Resume apixaban at least 6 hours after the procedure if adequate hemostasis is achieved 3

Monitoring Recommendations

• Regular assessment for signs of bleeding
• Periodic monitoring of renal function, especially in elderly patients
• Evaluate for drug interactions, particularly with strong inhibitors of both CYP3A4 and P-glycoprotein 3

The appropriate dosing of apixaban is critical for balancing stroke prevention benefits against bleeding risks. Following the established dosing criteria is essential to ensure optimal outcomes in patients with non-valvular atrial fibrillation.