What is the dose of Eliquis (apixaban)?

Apixaban (Eliquis) Dosing Guidelines

The standard dose of apixaban (Eliquis) is 5 mg twice daily for most patients with nonvalvular atrial fibrillation, with a reduced dose of 2.5 mg twice daily for patients who have at least two of the following characteristics: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1

Standard Dosing for Nonvalvular Atrial Fibrillation

• The recommended dose for most patients with nonvalvular atrial fibrillation is 5 mg taken orally twice daily 1, 2
• Apixaban has been shown to be effective in reducing stroke, systemic embolism, and mortality compared to warfarin in patients with nonvalvular atrial fibrillation 2
• The efficacy and safety of apixaban 5 mg twice daily was established in the ARISTOTLE trial, which demonstrated fewer overall strokes, systemic emboli, and major bleeding events compared to warfarin 2

Dose Reduction Criteria

Reduce the dose to 2.5 mg twice daily if the patient has at least two of the following:

• Age greater than or equal to 80 years 1, 2
• Body weight less than or equal to 60 kg 1, 2
• Serum creatinine greater than or equal to 1.5 mg/dL 1, 2

Special Populations

Renal Impairment

• For patients with end-stage renal disease (ESRD) on hemodialysis: 5 mg twice daily, reduced to 2.5 mg twice daily if age ≥80 years or body weight ≤60 kg 2
• Patients with severe renal impairment (CrCl <15 mL/min) were excluded from clinical trials with apixaban 2
• For patients with CrCl 25-30 mL/min, apixaban caused less bleeding than warfarin, with conventional dosing (5 mg twice daily) appearing appropriate based on pharmacokinetic data 3

Hepatic Impairment

• Avoid use in patients with severe hepatic impairment 2
• Patients with elevated transaminases >2 times the upper limit of normal or total bilirubin >1.5 times the upper limit of normal were excluded from clinical trials 2

Drug Interactions

• For patients receiving apixaban doses of 5 mg or 10 mg twice daily, reduce the dose by 50% when coadministered with drugs that are combined P-glycoprotein (P-gp) and strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, ritonavir) 1
• In patients already taking 2.5 mg twice daily, avoid coadministration with combined P-gp and strong CYP3A4 inhibitors 1

Dosing for Other Indications

DVT/PE Treatment

• Initial treatment: 10 mg taken orally twice daily for the first 7 days 1
• Continued treatment: 5 mg taken orally twice daily after the initial 7 days 1

DVT/PE Prophylaxis After Hip or Knee Replacement

• 2.5 mg taken orally twice daily 1
• Initial dose should be taken 12 to 24 hours after surgery 1
• For hip replacement: recommended duration is 35 days 1
• For knee replacement: recommended duration is 12 days 1

Reduction in Risk of Recurrence of DVT/PE

• 2.5 mg taken orally twice daily after at least 6 months of treatment for DVT or PE 1

Clinical Considerations and Pitfalls

• Studies show that inappropriate dose reduction is common in clinical practice, with up to 60.8% of patients receiving reduced doses not meeting criteria for dose reduction 4
• Inappropriate underdosing may compromise efficacy in stroke prevention 4
• Patients with one dose-reduction criterion still benefit from the standard 5 mg twice daily dose, with similar safety and efficacy compared to warfarin 5
• If a dose is missed, it should be taken as soon as possible on the same day and twice-daily administration should be resumed; the dose should not be doubled to make up for a missed dose 1
• For elective surgery or invasive procedures with moderate/high bleeding risk, discontinue apixaban at least 48 hours prior; for procedures with low bleeding risk, discontinue at least 24 hours prior 1

Monitoring and Follow-up

• Unlike warfarin, routine coagulation monitoring is not required 2
• The rapid onset and offset of action means bridging with parenteral anticoagulant therapy is not needed during initiation 2
• Strict compliance is critical as missing even one dose could result in a period without protection from thromboembolism 2
• When switching from warfarin to apixaban, warfarin should be discontinued and apixaban started when the INR is below 2.0 1

By following these dosing guidelines, clinicians can optimize the benefits of apixaban in reducing stroke and systemic embolism while minimizing bleeding risks in patients with atrial fibrillation and other indications.