What is the initial dosing of Eliquis (apixaban) for new onset atrial fibrillation?

Initial Dosing of Eliquis (Apixaban) for New Onset Atrial Fibrillation

For most patients with new onset atrial fibrillation, the recommended initial dose of apixaban is 5 mg taken orally twice daily. 1

Standard Dosing and Dose Reduction Criteria

Standard Dose

• The standard dose of 5 mg twice daily is appropriate for most patients with nonvalvular atrial fibrillation 2
• This dosing regimen was established in the ARISTOTLE trial, which demonstrated apixaban's efficacy in reducing stroke and systemic embolism compared to warfarin (HR 0.79,95% CI 0.66-0.95) 2

Dose Reduction Criteria

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

• Age ≥80 years 1
• Body weight ≤60 kg 1
• Serum creatinine ≥1.5 mg/dL 1

Renal Considerations

• For patients with end-stage renal disease on hemodialysis: 5 mg twice daily, reduced to 2.5 mg twice daily if age ≥80 years or body weight ≤60 kg 2
• Apixaban should be used with caution in patients with severe renal impairment (CrCl 15-29 mL/min) 3
• Apixaban should not be used in patients with CrCl <15 mL/min who are not on dialysis 2

Clinical Evidence Supporting Dosing Recommendations

• In the ARISTOTLE trial, apixaban 5 mg twice daily demonstrated a 21% reduction in stroke or systemic embolism compared to warfarin 2
• Apixaban also showed a 31% reduction in major bleeding compared to warfarin in the same trial 2
• For patients meeting dose reduction criteria, the 2.5 mg twice daily dose has been shown to maintain efficacy while reducing bleeding risk 2

Common Pitfalls in Apixaban Dosing

• Inappropriate dose reduction: Studies show that approximately 60% of patients receiving reduced-dose apixaban (2.5 mg twice daily) do not meet criteria for dose reduction 4
• Impact of inappropriate dosing: Underdosing may lead to suboptimal stroke prevention, while overdosing increases bleeding risk 4
• Age-based errors: Advanced age alone is not sufficient for dose reduction unless combined with low weight or elevated creatinine 1, 4

Special Considerations

Patients Undergoing 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
• Resume apixaban once adequate hemostasis is established 1

Concomitant Antiplatelet Therapy

• If the patient requires antiplatelet therapy (e.g., recent PCI), clopidogrel is the P2Y12 inhibitor of choice when combined with apixaban 2
• The safety of combining apixaban with antiplatelet agents has not been well established and may increase bleeding risk 2

Monitoring After Initiation

• No routine coagulation monitoring is required 2
• Assess for signs of bleeding or thromboembolism 2
• Evaluate renal function periodically, as declining renal function may necessitate dose adjustment 1

Remember that proper dosing of apixaban is essential to balance stroke prevention benefits against bleeding risks. The decision should be based on careful assessment of the patient's age, weight, and renal function.