From the Guidelines
When prescribing Eliquis (apixaban) for the first time, the initial dose for atrial fibrillation is 5 mg twice daily, but it should be reduced to 2.5 mg twice daily if the patient has at least two of the following: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL, as recommended by the most recent guidelines 1.
Key Considerations
- The dosage adjustment is crucial to minimize the risk of bleeding and ensure the efficacy of the treatment.
- It is essential to assess renal function, liver function, and bleeding risk before prescribing apixaban, as well as to check for potential drug interactions, particularly with strong CYP3A4 and P-gp inhibitors or inducers.
- Patients should be counseled to take Eliquis consistently with or without food, avoid missing doses, and continue taking it unless directed otherwise by their healthcare provider.
Important Interactions
- Apixaban is a substrate of P-glycoprotein and CYP3A4, and its dose should be reduced to 2.5 mg twice daily when combined with strong CYP3A4 and P-gp inhibitors, such as itraconazole, systemic ketoconazole, clarithromycin, or ritonavir 1.
- The use of apixaban with rifampin, a strong CYP3A4 inducer, should be avoided due to the potential for reduced apixaban efficacy.
Monitoring and Patient Education
- Patients should be informed about the bleeding risks associated with apixaban and when to seek medical attention.
- It is crucial to educate patients about the importance of informing all their healthcare providers about their Eliquis use to minimize the risk of drug interactions and ensure safe treatment.
Mechanism of Action
- Apixaban works by directly inhibiting Factor Xa in the coagulation cascade, preventing thrombin formation and clot development, with predictable anticoagulation effects that do not require routine monitoring 1.
From the FDA Drug Label
2.1 Reduction of Risk of Stroke and Systemic Embolism in Patients with Nonvalvular Atrial Fibrillation The recommended dose is 2.5 mg twice daily in patients with at least two of the following characteristics:
- age greater than or equal to 80 years
- body weight less than or equal to 60 kg
- serum creatinine greater than or equal to 1.5 mg/dL For other patients, the recommended dose is 5 mg taken orally twice daily.
The initial prescription protocol for Eliquis (apixaban) is 5 mg taken orally twice daily for patients without specific characteristics that require dose adjustment, and 2.5 mg twice daily for patients with at least two of the specified characteristics 2.
From the Research
Initial Prescription Protocol for Eliquis (Apixaban)
The initial prescription protocol for Eliquis (apixaban) can be determined based on the patient's specific condition and characteristics.
- For patients with nonvalvular atrial fibrillation, the standard dose of apixaban is 5 mg twice daily 3.
- However, for patients with at least two dose-reduction criteria (80 years or older, weight 60 kg or less, and creatinine level 1.5 mg/dL or higher), the reduced dose of apixaban is 2.5 mg twice daily 3.
- Patients with chronic kidney disease stage 4 and 5, including those on hemodialysis, may receive apixaban 5 mg twice daily or 2.5 mg twice daily, depending on their individual characteristics and renal function 4.
- The Food and Drug Administration allows the use of apixaban in patients with end-stage renal disease on hemodialysis 5.
Dose Reduction Criteria
The dose reduction criteria for apixaban include:
- Age 80 years or older
- Weight 60 kg or less
- Creatinine level 1.5 mg/dL or higher Patients with at least two of these criteria should receive the reduced dose of 2.5 mg twice daily 3.
Special Considerations
- Patients with renal impairment should be closely monitored, as apixaban is eliminated by the kidneys and its anticoagulant action may be increased in renal failure 6, 5.
- Apixaban is a substrate for various cytochrome P450 isoenzymes and for P-glycoprotein, creating a risk of multiple drug-drug interactions 6.