Apixaban Dosing Regimen for Pulmonary Embolism Treatment
For pulmonary embolism treatment, apixaban should be administered at 10 mg twice daily for the first 7 days, followed by 5 mg twice daily for at least 3 months, with an option to reduce to 2.5 mg twice daily after at least 6 months for extended prophylaxis. 1, 2
Initial Treatment Phase
- First 7 days: 10 mg twice daily 1, 2
- After 7 days: 5 mg twice daily 1, 2
- No initial parenteral anticoagulation (such as heparin) is required, unlike traditional therapy 1
- Treatment should begin as soon as diagnosis is confirmed 1
Treatment Duration
- Minimum duration: At least 3 months of anticoagulation therapy 1
- Extended treatment: Consider continuing beyond 3 months based on risk factors 3, 1
- Dose reduction for extended treatment: After at least 6 months of treatment at standard doses, the dose may be reduced to 2.5 mg twice daily for extended prophylaxis 1, 2
Special Considerations
- Renal impairment: For patients with severe renal impairment (creatinine clearance <30 mL/min), unfractionated heparin followed by vitamin K antagonists is preferred over apixaban 1
- Temporary interruption for procedures:
Indications for Extended Treatment
- Recurrent venous thromboembolism
- Unprovoked pulmonary embolism
- PE associated with persistent risk factors
- PE associated with antiphospholipid antibody syndrome 1
Clinical Evidence and Benefits
Apixaban has demonstrated non-inferiority to conventional therapy (heparin/warfarin) for preventing recurrent venous thromboembolism (RR 0.84; 95% CI 0.60-1.18) with significantly reduced major bleeding risk (RR 0.31; 95% CI 0.17-0.55; P<0.001) in the AMPLIFY trial 1. The AMPLIFY-J study in Japanese patients confirmed these findings, showing lower rates of major/clinically relevant non-major bleeding with apixaban (7.5%) compared to well-controlled UFH/warfarin (28.2%) 4.
Important Warnings
- Premature discontinuation: Stopping apixaban increases thrombotic risk; if discontinuation is necessary (other than for bleeding), consider alternative anticoagulation 2
- Inappropriate dose reduction: The 2.5 mg twice daily dose should only be used after at least 6 months of therapy at the standard dose 1
- Monitoring: Regular assessment of renal function, hepatic function, and bleeding risk is recommended for patients on extended anticoagulation 1
Missed Dose Management
If a dose is missed, take it as soon as possible on the same day and resume twice-daily administration. Do not double the dose to make up for a missed dose 2.