What is the initial dosing of Eliquis (apixaban) for a newly diagnosed atrial flutter patient?

Apixaban Dosing for Newly Diagnosed Atrial Flutter

For patients with newly diagnosed atrial flutter, the recommended initial dose of apixaban (Eliquis) is 5 mg taken orally twice daily for most patients. 1, 2

Standard Dosing Regimen

• The standard dose of 5 mg twice daily is appropriate for most patients with nonvalvular atrial flutter, as atrial flutter carries similar thromboembolic risks as atrial fibrillation 3, 4
• Anticoagulation therapy for atrial flutter follows the same recommendations as for atrial fibrillation, as explicitly stated in guidelines 3
• The efficacy of this dosing regimen was established in the ARISTOTLE trial, which demonstrated apixaban's superiority in reducing stroke and systemic embolism compared to warfarin 1

Dose Reduction Criteria

• Reduce the dose to 2.5 mg twice daily if the patient has at least two of the following characteristics 1, 2:

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

• This dose reduction strategy helps maintain efficacy while reducing bleeding risk in vulnerable populations 1

Renal Considerations

• For patients with severe renal impairment (CrCl 15-29 mL/min), the standard dosing recommendations still apply, with appropriate dose reduction based on age and weight criteria 1, 5
• Apixaban should not be used in patients with CrCl <15 mL/min who are not on dialysis 1
• For patients on hemodialysis, the recommended dose is 5 mg twice daily, reduced to 2.5 mg twice daily if age ≥80 years or body weight ≤60 kg 1

Initiating Therapy

• Start apixaban immediately upon diagnosis if there are no contraindications 3
• No loading dose is required; begin with the appropriate twice-daily regimen 2
• If converting from warfarin to apixaban, discontinue warfarin and start apixaban when the INR is below 2.0 2

Monitoring After Initiation

• No routine coagulation monitoring is required 1
• Evaluate renal function before initiation and at least annually thereafter, or more frequently in patients with declining renal function 2
• Assess for signs of bleeding or thromboembolism at follow-up visits 1

Special Considerations

• If the patient requires concomitant antiplatelet therapy, carefully assess bleeding risk as this combination increases bleeding risk 1
• Diltiazem use with apixaban may increase bleeding risk due to pharmacokinetic interactions, requiring careful monitoring 6
• Inappropriate underdosing of apixaban (using 2.5 mg twice daily when 5 mg twice daily is indicated) has been associated with increased all-cause mortality 7

Risk Assessment

• Use the CHA₂DS₂-VASc score to assess stroke risk in patients with atrial flutter, following the same approach as for atrial fibrillation 3
• Anticoagulation is recommended for patients with a CHA₂DS₂-VASc score of 2 or greater 3
• For patients with a CHA₂DS₂-VASc score of 1, anticoagulation may be considered 3