Guidelines for Eliquis (Apixaban) Dosages
The standard dose of Eliquis (apixaban) is 5 mg twice daily for most patients, with specific dose reduction to 2.5 mg twice daily required for patients who meet at least two of the following criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1
Standard Dosing for Atrial Fibrillation
For patients with non-valvular atrial fibrillation:
- Standard dose: 5 mg twice daily 2, 1
- Reduced dose: 2.5 mg twice daily (only if patient meets ≥2 of the following criteria):
Dosing for Other Indications
Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)
- Initial treatment: 10 mg twice daily for the first 7 days
- Maintenance treatment: 5 mg twice daily after the first 7 days
- Extended prevention: 2.5 mg twice daily after at least 6 months of treatment 1
Prophylaxis Following Hip or Knee Replacement Surgery
- 2.5 mg twice daily starting 12-24 hours after surgery
- Duration: 35 days for hip replacement; 12 days for knee replacement 1
Renal Dosing Considerations
Apixaban has lower renal clearance (27%) compared to other direct oral anticoagulants, making it potentially preferable in patients with renal impairment 2, 3:
| Creatinine Clearance (CrCl) | Recommended Dosing |
|---|---|
| >30 mL/min | Standard dosing (5 mg twice daily or 2.5 mg twice daily if meeting dose reduction criteria) |
| 15-30 mL/min | Standard dosing (5 mg twice daily or 2.5 mg twice daily if meeting dose reduction criteria) |
| <15 mL/min or on dialysis | 2.5 mg twice daily (regardless of other criteria) [3] |
The ARISTOTLE trial data showed that apixaban caused less bleeding than warfarin in patients with CrCl 25-30 mL/min, with even greater reductions in bleeding compared to patients with CrCl >30 mL/min 4.
Drug Interactions
Dose adjustments are necessary when apixaban is co-administered with certain medications:
P-glycoprotein and strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, ritonavir, clarithromycin):
- For patients already on 5 mg twice daily: Reduce to 2.5 mg twice daily
- For patients already on 2.5 mg twice daily: Avoid apixaban use 2
P-glycoprotein and CYP3A4 inducers (e.g., rifampin, carbamazepine, phenytoin, St. John's wort):
- Avoid concurrent use due to reduced apixaban effectiveness 2
Temporary Interruption for Procedures
When interrupting apixaban for surgical or invasive procedures 1:
- Low bleeding risk procedures: Discontinue apixaban at least 24 hours before procedure
- Moderate to high bleeding risk procedures: Discontinue apixaban at least 48 hours before procedure
| Procedure Bleeding Risk | Last Apixaban Dose Before Procedure |
|---|---|
| Low bleeding risk | 1 day before (CrCl >25 mL/min) |
| High bleeding risk | 2 days before (CrCl >25 mL/min) |
For patients with lower CrCl, consider holding for an additional 1-3 days, especially for high bleeding risk procedures 2.
Important Clinical Considerations
Off-label underdosing is common but not recommended: Studies show that approximately 15-17% of patients receive lower-than-recommended doses of apixaban 5. This practice should be avoided as it may compromise stroke prevention without improving safety.
Single dose-reduction criterion: Patients with only one dose-reduction criterion (e.g., only age ≥80 years) should receive the standard 5 mg twice daily dose. Research shows these patients derive consistent benefits with the standard dose compared to warfarin 6.
Missed doses: If a dose is missed, take it as soon as possible on the same day and resume the normal twice-daily schedule. Do not double the dose to make up for a missed dose 1.
Switching between anticoagulants:
- From warfarin to apixaban: Start apixaban when INR is below 2.0
- From apixaban to warfarin: Consider overlapping with parenteral anticoagulant until INR reaches acceptable range 1
By following these evidence-based guidelines for Eliquis dosing, clinicians can optimize both efficacy in preventing thromboembolic events and safety regarding bleeding risk.