Apixaban Dosing for Non-valvular Atrial Fibrillation
The recommended dose of Eliquis (apixaban) 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 for patients with at least two of the following characteristics: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1, 2
Standard Dosing Regimen
- 5 mg twice daily is the standard dose for most patients with non-valvular atrial fibrillation 2
- This dosing has demonstrated superior efficacy and safety compared to warfarin, with:
- 21% reduction in stroke or systemic embolism
- 11% reduction in all-cause mortality
- 31% reduction in major bleeding 1
Dose Reduction Criteria
Reduce dose to 2.5 mg twice daily if the patient has at least two of:
Special Populations
Renal Impairment
- For severe renal impairment (CrCl 15-29 mL/min): 2.5 mg twice daily 1
- Apixaban is the only DOAC specifically mentioned in guidelines for use in dialysis patients, at a dose of 2.5 mg twice daily 1
Perioperative Management
- Discontinue apixaban at least 48 hours before elective surgery with moderate/high bleeding risk
- Discontinue at least 24 hours before procedures with low bleeding risk
- Resume after adequate hemostasis is established 2
Common Pitfalls in Apixaban Dosing
Inappropriate Underdosing
- Studies show 34-39% of patients receive inappropriately reduced doses of apixaban 3, 4
- Most common in elderly patients (≥80 years) who only meet one dose reduction criterion 5
- Underdosing may lead to inadequate stroke prevention while not necessarily reducing bleeding risk
Inappropriate Overdosing
- Less common (0.7-5% of prescriptions) but potentially dangerous 3, 5
- Can increase bleeding risk without additional thromboembolism prevention benefit
Monitoring Requirements
- No routine coagulation monitoring required 1
- Regular assessment of renal function is essential 1
- Monitor for signs of bleeding and drug interactions, particularly with strong inhibitors of CYP3A4 and P-glycoprotein 1
Important Considerations
- Premature discontinuation increases thrombotic risk - consider alternative anticoagulation if stopping for reasons other than bleeding 2
- Apixaban should be taken consistently at approximately 12-hour intervals
- If a dose is missed, take as soon as possible on the same day and resume normal schedule (do not double the dose) 2
The FDA-approved labeling and clinical guidelines strongly support the standard 5 mg twice daily dosing for most patients with non-valvular atrial fibrillation, with clear criteria for dose reduction to 2.5 mg twice daily when appropriate.