What is the recommended dosing of Eliquis (apixaban) for a patient with new onset atrial fibrillation?

Apixaban (Eliquis) Dosing for New Onset Atrial Fibrillation

For patients with new onset atrial fibrillation, the recommended dose of apixaban is 5 mg taken orally twice daily, with a reduced dose of 2.5 mg twice daily 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

Standard Dosing Regimen

The FDA-approved dosing for apixaban in patients with nonvalvular atrial fibrillation is:

• Standard dose: 5 mg orally twice daily for most patients 1
• Reduced dose: 2.5 mg orally twice daily for patients with at least two of the following characteristics 1:
  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL

Dosing Considerations Based on Patient Factors

Renal Function

• For patients with normal to mild renal impairment (CrCl ≥50 mL/min), the standard dose of 5 mg twice daily is appropriate 2, 3
• For patients with severe renal impairment (CrCl 15-29 mL/min), apixaban can still be used at 2.5 mg twice daily if they meet the dose reduction criteria 3
• Apixaban is the only DOAC specifically mentioned in guidelines for use in dialysis patients, with a recommended dose of 2.5 mg twice daily 3

Age, Weight, and Renal Function Interactions

• The dose reduction criteria are not based on a single factor but require at least two of the three criteria to be present 1
• Patients with only one dose-reduction criterion should receive the standard 5 mg twice daily dose 4
• Clinical outcomes data from the ARISTOTLE trial showed that patients with only one dose-reduction criterion still benefit from the standard 5 mg twice daily dose compared to warfarin 4

Common Prescribing Errors to Avoid

• Studies show that apixaban is frequently underdosed in clinical practice, with up to 60.8% of patients receiving reduced doses not meeting the criteria for dose reduction 5
• Inappropriate dose reduction is most commonly associated with advanced age, even when patients don't meet the full criteria for dose reduction 5
• Underdosing may compromise the efficacy of stroke prevention without providing additional safety benefits 6

Administration Guidelines

• If a dose is missed, it should be taken as soon as possible on the same day, and twice-daily administration should be resumed 1
• Do not double the dose to make up for a missed dose 1
• No routine coagulation monitoring is required for apixaban 3
• Regular monitoring of renal function is essential for patients on apixaban 3

Special Situations

Surgery and Procedures

• Apixaban should be discontinued at least 48 hours prior to elective surgery with moderate or high bleeding risk 1
• For procedures with low bleeding risk, discontinue apixaban at least 24 hours before 1
• Bridging anticoagulation is not generally required during the 24-48 hours after stopping apixaban 1
• Restart apixaban as soon as adequate hemostasis has been established 1

Converting Between Anticoagulants

• When switching from warfarin to apixaban: Discontinue warfarin and start apixaban when INR is below 2.0 1
• When switching from apixaban to warfarin: Consider using a parenteral anticoagulant bridge 1
• When switching from apixaban to other anticoagulants: Begin the new anticoagulant at the time the next dose of apixaban would have been taken 1

Efficacy and Safety Profile

Apixaban has demonstrated superior safety compared to warfarin, with:

• 21% reduction in stroke or systemic embolism
• 31% reduction in major bleeding
• 11% reduction in all-cause mortality 3

This favorable risk-benefit profile makes apixaban an excellent choice for anticoagulation in patients with new onset atrial fibrillation.