Apixaban (Eliquis) Dosing Regimens for Anticoagulation
The standard dose of apixaban for most patients requiring anticoagulation for atrial fibrillation is 5 mg taken orally twice daily, with dose reduction to 2.5 mg twice daily for patients with at least two of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1
Dosing for Different Indications
Nonvalvular Atrial Fibrillation
- Standard dose: 5 mg twice daily 1
- Reduced dose (2.5 mg twice daily) if patient has at least two of:
- For patients with end-stage renal disease requiring hemodialysis: 5 mg twice daily, reduced to 2.5 mg twice daily if age ≥80 years or body weight ≤60 kg 2, 3
Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Treatment
- Initial treatment: 10 mg twice daily for the first 7 days 1
- Maintenance treatment: 5 mg twice daily after the initial 7 days 1
- Extended treatment to reduce recurrence risk: 2.5 mg twice daily after at least 6 months of treatment 1, 4
DVT Prophylaxis Following Hip or Knee Replacement Surgery
Special Considerations
Renal Function
- No dose adjustment needed for mild to moderate renal impairment 1
- For patients with creatinine clearance 15-30 mL/min, careful monitoring is advised 2
- In patients with end-stage kidney disease on dialysis, standard-dose apixaban (5 mg twice daily) was associated with lower risks of stroke/systemic embolism and death compared to reduced-dose apixaban or warfarin 3
Perioperative Management
- For procedures with low bleeding risk: discontinue apixaban at least 24 hours before procedure 1
- For procedures with moderate to high bleeding risk: discontinue apixaban at least 48 hours before procedure 1
- For very high bleeding risk procedures (e.g., intracranial neurosurgery or neuraxial anesthesia): longer interruption times up to 5 days may be necessary 2
- Bridging anticoagulation during the interruption period is not generally required 1, 2
- Resume apixaban as soon as adequate hemostasis has been established, typically at least 6 hours after the end of the procedure 1, 2
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/to other anticoagulants: begin the new agent at the usual time of the next scheduled dose of the previous agent 1
Important Precautions
- Premature discontinuation increases thrombotic risk; consider alternative anticoagulation if stopping for reasons other than bleeding 1
- Risk of spinal/epidural hematoma in patients receiving neuraxial anesthesia or undergoing spinal puncture 1
- If a dose is missed, take it as soon as possible on the same day and resume the normal twice-daily schedule; do not double the dose 1
Monitoring
- Routine monitoring of anticoagulant effect is not required 2
- For perioperative management, biological monitoring of drug concentrations may be considered in high-risk procedures 2
- Monitor renal function periodically, especially in elderly patients or those with risk factors for renal impairment 2
Potential Pitfalls and Caveats
- Inappropriate dose reduction: In the AUGUSTUS trial, less than half of patients receiving reduced-dose apixaban actually met the dose-reduction criteria 6
- Concomitant use with P2Y12 inhibitors (e.g., clopidogrel) in patients with atrial fibrillation undergoing PCI increases bleeding risk; clopidogrel is preferred over more potent P2Y12 inhibitors in this setting 2
- Avoid concomitant use with strong dual inhibitors of CYP3A4 and P-glycoprotein 2
- In patients with end-stage kidney disease on dialysis, standard-dose apixaban (5 mg twice daily) may be preferred over reduced-dose (2.5 mg twice daily) when no other dose-reduction criteria are present 3