What is the recommended dose of Eliquis (apixaban) for a patient with atrial fibrillation (AFib) and deep vein thrombosis (DVT) prophylaxis?

Apixaban Dosing for Atrial Fibrillation and DVT Prophylaxis

For patients with both atrial fibrillation and DVT prophylaxis needs, the recommended dose of apixaban (Eliquis) is 5 mg twice daily, with dose reduction to 2.5 mg twice daily for patients with at least two of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1, 2, 3

Standard Dosing Recommendations

For Atrial Fibrillation:

• Standard dose: 5 mg twice daily 1, 2, 3
• Reduced dose: 2.5 mg twice daily if patient has at least two of:
  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL 1, 3

For DVT Prophylaxis:

• Post-surgical prophylaxis: 2.5 mg twice daily (typically for 12 days after knee replacement or 35 days after hip replacement) 3
• DVT treatment: 10 mg twice daily for 7 days, followed by 5 mg twice daily 1, 3
• Extended prevention: 2.5 mg twice daily after at least 6 months of treatment 1, 3

Clinical Decision Algorithm

1. Determine if patient has both conditions:

   • Confirmed atrial fibrillation
   • Need for DVT prophylaxis (post-surgical or extended prevention)

2. Assess renal function:

   • Calculate creatinine clearance (CrCl)
   • Apixaban can be used at standard doses even with CrCl 15-30 mL/min 1
   • Apixaban is the only DOAC specifically mentioned for use in dialysis patients at 2.5 mg twice daily 2

3. Evaluate dose reduction criteria:

   • Count how many criteria the patient meets (age ≥80 years, weight ≤60 kg, creatinine ≥1.5 mg/dL)
   • If ≥2 criteria: Use 2.5 mg twice daily
   • If <2 criteria: Use 5 mg twice daily 1, 3

4. Consider treatment phase:

   • For acute DVT treatment with concurrent AF: Use the higher dose (10 mg twice daily for 7 days, then 5 mg twice daily) unless dose reduction criteria are met 1, 3
   • For extended prevention with concurrent AF: Use 5 mg twice daily (or 2.5 mg if dose reduction criteria are met) 2, 3

Important Clinical Considerations

• The AUGUSTUS trial demonstrated that apixaban was associated with lower bleeding rates compared to vitamin K antagonists in patients with atrial fibrillation, without significant differences in efficacy outcomes 2, 4

• Patients with one dose-reduction criterion still benefit from the standard 5 mg twice daily dose with similar safety profile compared to those with no dose-reduction criteria 5

• Apixaban should be discontinued at least 48 hours prior to elective surgery with moderate/high bleeding risk and at least 24 hours before procedures with low bleeding risk 2, 3

• When coadministered with combined P-gp and strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, ritonavir), reduce the dose by 50% for patients on 5 mg or 10 mg twice daily regimens 3

• Regular monitoring of renal function is essential, though routine coagulation monitoring is not required 2

Efficacy and Safety Profile

Compared to warfarin, apixaban demonstrates:

• 21% reduction in stroke or systemic embolism
• 31% reduction in major bleeding
• 11% reduction in all-cause mortality
• 49% reduction in hemorrhagic stroke 2

This makes apixaban an excellent choice for patients requiring both atrial fibrillation and DVT prophylaxis management, with a favorable risk-benefit profile across various patient populations 6, 5.