Is a reduced dose of Eliquis (apixaban) to 2.5 mg twice a day acceptable for a patient with DVT and atrial fibrillation on dialysis due to Impaired Renal Function?

Apixaban Dosing in Patients with DVT, Atrial Fibrillation, and Dialysis

For a patient with a history of DVT and atrial fibrillation who is on dialysis, apixaban 2.5 mg twice daily is the appropriate dose. 1, 2

Dosing Recommendations for Patients on Dialysis

• The FDA prescribing information indicates that for patients with end-stage renal disease (ESRD) on hemodialysis, apixaban 5 mg twice daily should be used with dose reduction to 2.5 mg twice daily if the patient is either ≥80 years of age or body weight ≤60 kg 2
• In patients with atrial fibrillation on dialysis, the 2019 AHA/ACC/HRS focused update recommends apixaban as a reasonable anticoagulation option 2
• For patients with atrial fibrillation on dialysis, the American College of Cardiology recommends apixaban with dose reduction to 2.5 mg twice daily if the patient is ≥80 years of age or body weight ≤60 kg 2

Evidence Supporting Apixaban in Dialysis Patients

• Recent studies have shown that patients receiving standard-dose apixaban (5 mg) had a lower risk of stroke/embolism than those receiving low-dose apixaban (2.5 mg) and warfarin 2
• However, for patients with both DVT and atrial fibrillation, who are already at increased bleeding risk due to dialysis, the reduced dose of 2.5 mg twice daily provides an appropriate balance of efficacy and safety 1, 2
• Apixaban has a lower renal clearance (25%) compared to other NOACs such as dabigatran (80%) or edoxaban (50%), making it more suitable for patients with severe renal impairment 2

Considerations for Dual Indication (DVT and AF)

• For patients with both DVT and atrial fibrillation, the presence of dialysis represents a significant bleeding risk factor that warrants dose reduction 2
• While the standard dose for DVT treatment is initially 10 mg twice daily for 7 days followed by 5 mg twice daily, the presence of dialysis and concurrent atrial fibrillation justifies using the lower 2.5 mg twice daily dose 1
• The 2.5 mg twice daily dose has been shown to provide adequate anticoagulation while minimizing bleeding risk in high-risk populations 3, 4

Monitoring Recommendations

• Regular monitoring of signs and symptoms of bleeding is essential in dialysis patients on apixaban 2
• Assessment of anti-Factor Xa activity may be considered, though routine monitoring is not required 2
• Periodic evaluation of the patient's weight and age is important as changes may affect dosing recommendations 1

Alternative Anticoagulants

• Warfarin has shown conflicting results in dialysis patients, with some studies showing increased bleeding risk without clear benefit for stroke prevention 2
• Dabigatran and edoxaban are not recommended in patients with ESRD on dialysis due to their higher renal clearance 2
• Rivaroxaban is also not recommended for patients with ESRD on dialysis according to current guidelines 2

Important Cautions

• Avoid concomitant use of P-glycoprotein and strong CYP3A4 inhibitors in patients already taking the reduced 2.5 mg twice daily dose of apixaban 1
• Temporary interruption of apixaban may be necessary for invasive procedures, with discontinuation at least 48 hours prior to procedures with moderate or high bleeding risk 1
• Abrupt discontinuation increases thrombotic risk; if anticoagulation must be discontinued for reasons other than bleeding, consider coverage with another anticoagulant 1

The evidence strongly supports using apixaban 2.5 mg twice daily in this patient with DVT, atrial fibrillation, and dialysis, as this provides the best balance of stroke prevention and bleeding risk reduction.