What is the recommended dose of Eliquis (apixaban)?

Recommended Dosing of Apixaban (Eliquis)

The standard dose of apixaban for most patients with nonvalvular atrial fibrillation is 5 mg taken orally twice daily. 1

Standard Dosing by Indication

• Nonvalvular Atrial Fibrillation (NVAF): 5 mg orally twice daily 2, 1
• Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Treatment: 10 mg orally twice daily for the first 7 days, followed by 5 mg orally twice daily 2, 1
• DVT/PE Prevention after Hip or Knee Replacement Surgery: 2.5 mg orally twice daily, starting 12-24 hours after surgery 1
  • For hip replacement: continue for 35 days 1
  • For knee replacement: continue for 12 days 1
• Reduction in Risk of Recurrent DVT/PE: 2.5 mg orally twice daily after at least 6 months of treatment for DVT or PE 1

Dose Reduction Criteria

For Nonvalvular Atrial Fibrillation

The dose should be reduced to 2.5 mg twice daily if the patient has at least two of the following characteristics 2, 1:

• Age ≥80 years
• Body weight ≤60 kg
• Serum creatinine ≥1.5 mg/dL (133 μmol/L)

Special Considerations for Renal Function

• Normal to Moderate Renal Impairment: No dose adjustment needed for patients with creatinine clearance >30 mL/min 2
• Severe Renal Impairment: For patients with end-stage renal disease on hemodialysis, 5 mg twice daily with reduction to 2.5 mg twice daily if age ≥80 years or body weight ≤60 kg 2

Clinical Evidence Supporting Dosing Recommendations

• The ARISTOTLE trial demonstrated that apixaban 5 mg twice daily reduced stroke or systemic embolism by 21% compared with warfarin, with a 31% reduction in major bleeding and 11% reduction in all-cause mortality 2
• Patients with only one dose-reduction criterion still benefit from the standard 5 mg twice daily dose, showing similar efficacy and safety profiles compared to those with no dose-reduction criteria 3
• Inappropriate dose reduction (using 2.5 mg twice daily when not indicated) may compromise efficacy without providing additional safety benefits 4, 5

Temporary Interruption for Procedures

• For elective surgery or invasive procedures with moderate/high bleeding risk: discontinue apixaban at least 48 hours prior 1
• For procedures with low bleeding risk: discontinue at least 24 hours prior 1
• For high hemorrhagic risk procedures (e.g., neurosurgery): consider longer interruption periods of up to 3-5 days 2
• Resume apixaban as soon as adequate hemostasis has been established 1

Important Warnings

• Premature Discontinuation: Stopping apixaban increases thrombotic risk; if discontinuation is necessary for reasons other than bleeding, consider alternative anticoagulation 1
• Missed Dose: If a dose is missed, take it as soon as possible on the same day and resume twice-daily administration; do not double the dose 1
• Spinal/Epidural Hematoma Risk: Patients receiving neuraxial anesthesia or undergoing spinal puncture are at risk; monitor frequently for neurological impairment 1

Switching Between Anticoagulants

• From warfarin to apixaban: Discontinue warfarin and start apixaban when INR is below 2.0 1
• From apixaban to warfarin: Consider bridging with parenteral anticoagulant until INR reaches acceptable range 1
• Between apixaban and other anticoagulants: Begin the new anticoagulant at the time the next dose of the previous anticoagulant would have been taken 1

Apixaban offers predictable anticoagulation without the need for routine monitoring, making it an attractive alternative to traditional vitamin K antagonists like warfarin for many patients requiring anticoagulation 6.