What is the recommended dosing of Eliquis (apixaban) for patients post pulmonary embolism?

Apixaban Dosing for Pulmonary Embolism Treatment

For patients with pulmonary embolism, apixaban should be administered at 10 mg twice daily for the first 7 days, followed by 5 mg twice daily for at least 3 months. 1, 2

Initial Treatment Phase

• Apixaban 10 mg twice daily for 7 days 1, 2
• No initial parenteral anticoagulation (such as heparin or LMWH) is required before starting apixaban, unlike some other direct oral anticoagulants 1
• Treatment can be initiated immediately upon diagnosis of PE, provided there are no contraindications 1

Maintenance Phase

• After the initial 7 days, reduce to 5 mg twice daily 1, 2
• Continue treatment for at least 3 months 1
• For patients with unprovoked PE or ongoing risk factors, extended anticoagulation may be necessary 1

Extended Treatment Phase (After 6 Months)

• For patients requiring extended anticoagulation beyond 6 months, the recommended dose is 2.5 mg twice daily 2
• This reduced dose maintains efficacy while decreasing bleeding risk in long-term therapy 3

Special Considerations

Dose Adjustments

• For patients taking combined P-glycoprotein (P-gp) and strong CYP3A4 inhibitors:
  • Reduce the dose by 50% (5 mg to 2.5 mg twice daily) 2
  • If already on 2.5 mg twice daily, avoid concomitant use 2

Renal Function

• No dose adjustment is required for mild to moderate renal impairment 4
• Use with caution in severe renal impairment (creatinine clearance <30 mL/min) 1

Missed Doses

• If a dose is missed, take it as soon as possible on the same day 2
• Resume twice-daily administration schedule 2
• Do not double the dose to make up for a missed dose 2

Perioperative Management

• Discontinue apixaban at least 48 hours prior to elective surgery with moderate/high bleeding risk 2
• Discontinue at least 24 hours prior to procedures with low bleeding risk 2
• Resume after adequate hemostasis has been established 2

Efficacy and Safety

• Apixaban has been shown to be non-inferior to conventional therapy (enoxaparin/warfarin) for the treatment of VTE 5
• Major bleeding occurs less frequently with apixaban (0.6%) compared to conventional therapy (1.8%) 5, 1
• The composite of major bleeding and clinically relevant non-major bleeding is significantly lower with apixaban (4.3%) compared to conventional therapy (9.7%) 1, 5

Cancer-Associated PE

• Apixaban is effective for cancer-associated VTE without increased risk of major bleeding compared to LMWH 6
• For extended treatment in cancer patients, reduced-dose apixaban (2.5 mg twice daily) is non-inferior to full-dose (5 mg twice daily) with lower bleeding risk 3

Common Pitfalls to Avoid

• Do not confuse the initial dosing (10 mg twice daily) with the maintenance dosing (5 mg twice daily) 2
• Do not administer loading doses of parenteral anticoagulants when initiating apixaban, as this increases bleeding risk 1
• Do not continue the initial higher dose beyond 7 days 1, 2
• Ensure proper transition when switching from or to other anticoagulants 2
• Monitor for drug interactions, particularly with combined P-gp and strong CYP3A4 inhibitors 2