What is the recommended dosing for Eliquis (apixaban) in patients with non-valvular atrial fibrillation or impaired renal function?

Apixaban (Eliquis) Dosing for Non-Valvular Atrial Fibrillation and Renal Impairment

For patients with non-valvular atrial fibrillation, the standard dose of apixaban is 5 mg twice daily, with a reduced dose of 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

Standard Dosing for Non-Valvular Atrial Fibrillation

• Standard dose: 5 mg twice daily orally 1
• This dose has been shown to reduce the risk of stroke or systemic embolism by 21%, all-cause mortality by 11%, and major bleeding by 31% compared to warfarin 3

Dose Reduction Criteria

Reduce to 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, 2

Renal Impairment Considerations

• Mild to moderate impairment (CrCl 15-50 mL/min): No dose adjustment needed unless patient meets at least two dose reduction criteria 1
• Severe impairment (CrCl 15-29 mL/min): 2.5 mg twice daily is recommended 3
• End-stage renal disease on hemodialysis: 5 mg twice daily with reduction to 2.5 mg twice daily for either age ≥80 years or body weight ≤60 kg 2
• CrCl <15 mL/min or not on dialysis: Apixaban is not recommended 2

Clinical Evidence Supporting Dosing

The ARISTOTLE trial demonstrated that apixaban was superior to warfarin with:

• Fewer overall strokes (both ischemic and hemorrhagic)
• Fewer systemic emboli
• Fewer major bleeding events
• Fewer intracranial bleeds
• Lower mortality 2

These benefits were independent of:

• Type of atrial fibrillation
• Risk profile
• CHADS₂ or CHA₂DS₂-VASc score
• Prior stroke history 2

Important Clinical 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

Monitoring

• No routine coagulation monitoring is required 3
• Regular monitoring of renal function is essential 3

Safety Profile

The safety profile of apixaban shows:

• 52% reduction in intracranial hemorrhage compared to warfarin
• 31% reduction in major bleeding events
• Similar rates of gastrointestinal bleeding compared to warfarin 3, 4

Special Populations

For patients with one dose-reduction criterion only (e.g., just advanced age or just low body weight), the standard 5 mg twice daily dose remains safe and efficacious compared to warfarin 5.

Remember that strict compliance with apixaban is critical, as missing doses could result in periods without adequate protection from thromboembolism 2.