What is the recommended dosing for Eliquis (apixaban) in the treatment of deep vein thrombosis (DVT)?

Apixaban Dosing for DVT Treatment

The recommended dosing for Eliquis (apixaban) in the treatment of deep vein thrombosis (DVT) is 10 mg taken orally twice daily for the first 7 days, followed by 5 mg taken orally twice daily for at least 3 months. 1

Dosing Schedule

The FDA-approved dosing regimen for apixaban in DVT treatment follows a two-phase approach:

1. Initial phase (first 7 days):

   • 10 mg orally twice daily

2. Maintenance phase (after first 7 days):

   • 5 mg orally twice daily
   • Continue for at least 3 months (duration depends on risk factors)

Duration of Therapy

The optimal duration of anticoagulation depends on several factors:

• For provoked DVT (with temporary risk factors): 3 months of therapy is typically sufficient
• For unprovoked DVT or patients with ongoing risk factors: Extended therapy may be warranted
• After completing at least 6 months of treatment, patients at risk for recurrence may be transitioned to a reduced dose of 2.5 mg twice daily for long-term secondary prevention 1

Dose Adjustments

Renal Impairment

• No dose adjustment needed for mild to moderate renal impairment
• Avoid use in patients with severe renal impairment (CrCl <15 mL/min)
• Use with caution in patients with CrCl 15-30 mL/min 2, 3

Hepatic Impairment

• Avoid use in patients with severe hepatic impairment
• Avoid in patients with hepatic disease associated with coagulopathy
• Not recommended in patients with transaminases >2 times the upper limit of normal or total bilirubin >1.5 times the upper limit of normal 2

Drug Interactions

• For patients receiving apixaban doses of 5 mg or 10 mg twice daily who require co-administration with combined P-glycoprotein (P-gp) and strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, ritonavir):
  • Reduce the dose by 50% 1

Clinical Evidence

The AMPLIFY trial demonstrated that apixaban (10 mg twice daily for 7 days followed by 5 mg twice daily for 6 months) was noninferior to conventional therapy (enoxaparin followed by warfarin) in preventing recurrent VTE or VTE-related death (2.3% vs 2.7%; relative risk, 0.84; 95% CI, 0.60-1.18) 2, 4.

Importantly, apixaban showed superior safety with significantly lower rates of major bleeding compared to conventional therapy (0.6% vs 1.8%; relative risk, 0.31; 95% CI, 0.17-0.55; P<0.001) 4.

Special Considerations

Missed Doses

• If a dose is missed, take it as soon as possible on the same day
• Resume twice-daily administration schedule
• Do not double the dose to make up for a missed dose 1

Perioperative Management

• Discontinue apixaban at least 48 hours prior to elective surgery with moderate/high bleeding risk
• Discontinue at least 24 hours prior to procedures with low bleeding risk
• Restart after adequate hemostasis is established 1

Switching Between Anticoagulants

• From warfarin to apixaban: Discontinue warfarin and start apixaban when INR is below 2.0
• From apixaban to warfarin: Discontinue apixaban and begin both parenteral anticoagulant and warfarin at the time the next dose of apixaban would have been taken 1

Monitoring

Unlike warfarin, routine coagulation monitoring is not required for apixaban. However, patients should be monitored for:

• Signs of bleeding
• Medication adherence
• Renal function changes
• Drug interactions

Potential Adverse Effects

• Major bleeding (though rates are lower than with conventional therapy)
• Clinically relevant non-major bleeding
• Rare cases of hypersensitivity reactions including skin manifestations 5

The fixed-dose regimen of apixaban simplifies DVT treatment compared to conventional therapy while providing effective prevention of recurrent VTE with a significantly improved safety profile.