What is the dosing and usage of Eliquis (apixaban) for patients requiring anticoagulation?

Apixaban (Eliquis) Dosing and Usage for Anticoagulation

The standard dosing of apixaban for patients requiring anticoagulation varies by indication, with 5 mg twice daily for atrial fibrillation, 10 mg twice daily for the first 7 days followed by 5 mg twice daily for DVT/PE treatment, and 2.5 mg twice daily for extended prevention of recurrent DVT/PE after at least 6 months of treatment. 1

Dosing by Indication

Atrial Fibrillation

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

Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Treatment

• Initial treatment: 10 mg orally twice daily for the first 7 days 2, 1
• Maintenance treatment: 5 mg orally twice daily after the first 7 days 2, 1
• Duration: Typically 3-6 months, depending on clinical scenario and risk factors 4

Prevention of Recurrent DVT/PE

• 2.5 mg orally twice daily after at least 6 months of treatment for DVT or PE 2, 1
• This reduced dose has been shown to be effective for secondary prevention while potentially reducing bleeding risk 2, 4

Prophylaxis Following Hip or Knee Replacement Surgery

• 2.5 mg orally twice daily 1
• Duration:
  • Hip replacement: 35 days 1
  • Knee replacement: 12 days 1

Special Populations and Considerations

Renal Function

• No dose adjustment needed for mild to moderate renal impairment 1, 5
• Use with caution in severe renal impairment (CrCl <15 mL/min) 2, 5
• Apixaban is approximately 27% renally cleared, making it less dependent on renal function than some other anticoagulants 5

Hepatic Impairment

• Avoid in severe hepatic impairment 2
• Use with caution in patients with elevated liver enzymes (>2x upper limit of normal) or total bilirubin >1.5x upper limit of normal 2

Elderly Patients

• Age alone does not require dose reduction unless other criteria are met 3
• Patients with isolated advanced age showed consistent benefits with the 5 mg twice daily dose compared to warfarin 3

Patients Undergoing Procedures

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

Patients with Atrial Fibrillation Undergoing PCI

• Apixaban has been studied in combination with P2Y12 inhibitors in patients with AF undergoing PCI 6
• Clopidogrel is the preferred P2Y12 inhibitor when combined with apixaban due to lower bleeding risk 2
• Appropriately dosed apixaban (both standard and reduced doses) showed favorable outcomes compared to vitamin K antagonists in this population 6

Practical Administration Considerations

• Apixaban can be taken with or without food 5
• If a dose is missed, take as soon as possible on the same day and resume twice-daily dosing; do not double the dose 1
• Half-life is approximately 12 hours 5
• No routine anticoagulation monitoring is required 4

Switching Between Anticoagulants

• From warfarin to apixaban: Discontinue warfarin and start apixaban when INR is below 2.0 1
• 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
• From apixaban to other anticoagulants: Discontinue apixaban and begin the new anticoagulant at the usual time of the next apixaban dose 1

Common Pitfalls and Caveats

• Inappropriate dose reduction: In clinical practice, reduced doses are sometimes prescribed to patients who don't meet criteria, potentially compromising efficacy 6
• Failure to adjust dose based on multiple criteria: Patients with at least two dose-reduction criteria should receive the reduced dose of 2.5 mg twice daily 1, 3
• Drug interactions: While apixaban has limited clinically relevant interactions with most medications, strong dual inhibitors of CYP3A4 and P-gp may increase apixaban exposure 5
• Missed doses: Patients should be educated about the importance of adherence and proper management of missed doses 1
• Perioperative management: Failure to appropriately time the discontinuation and resumption of apixaban around procedures can increase bleeding or thrombotic risk 1