Should Eliquis (apixaban) be taken daily for a history of atrial fibrillation (AFib)?

Apixaban (Eliquis) Should Be Taken Twice Daily for History of Atrial Fibrillation

For patients with a history of atrial fibrillation, apixaban (Eliquis) should be taken twice daily at a dose of 5 mg (or 2.5 mg if meeting dose reduction criteria) to effectively prevent stroke and systemic embolism. 1, 2

Standard Dosing Regimen

• The standard recommended dose of apixaban for nonvalvular atrial fibrillation is 5 mg taken orally twice daily 1, 2
• Twice-daily dosing is essential for maintaining consistent anticoagulation levels throughout the day, as apixaban has a half-life of 9-14 hours 1
• Apixaban has demonstrated superior efficacy compared to warfarin in reducing stroke and systemic embolism (hazard ratio 0.79,95% CI 0.66-0.95) 1, 2
• Missing doses can increase the risk of thrombotic events; if a dose is missed, it should be taken as soon as possible on the same day, and twice-daily administration should be resumed (do not double the dose) 2

Dose Reduction Criteria

• The dose should be reduced 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

• Inappropriate dose reduction (when not meeting criteria) may compromise stroke prevention efficacy 3, 4

Clinical Evidence Supporting Twice-Daily Dosing

• The ARISTOTLE trial, which established apixaban's efficacy, used a twice-daily dosing regimen and demonstrated a 21% reduction in stroke or systemic embolism compared to warfarin 1, 5
• Apixaban also showed a 31% reduction in major bleeding compared to warfarin in the ARISTOTLE trial 1, 5
• The AVERROES trial demonstrated that apixaban was superior to aspirin in preventing stroke in patients deemed unsuitable for vitamin K antagonist therapy 1, 6

Renal Considerations

• For patients with severe renal impairment (CrCl 15-30 mL/min), the standard 5 mg twice daily dose is still recommended unless other dose reduction criteria are met 1
• For patients with end-stage renal disease on hemodialysis, apixaban 5 mg twice daily is recommended, reduced to 2.5 mg twice daily if meeting other dose reduction criteria 1, 5
• Apixaban is contraindicated in patients with CrCl <15 mL/min who are not on dialysis 1

Common Pitfalls to Avoid

• Underdosing patients who don't meet dose reduction criteria may lead to inadequate anticoagulation and increased stroke risk 3
• Switching from twice-daily to once-daily dosing is not supported by evidence and may compromise efficacy 5, 3
• Premature discontinuation of apixaban increases the risk of thrombotic events; if anticoagulation must be discontinued for reasons other than bleeding, consider coverage with another anticoagulant 2
• Temporary interruption for surgery requires stopping apixaban at least 48 hours prior to procedures with high bleeding risk and at least 24 hours prior to procedures with low bleeding risk 2

Risk Assessment and Monitoring

• Stroke risk should be assessed using the CHA₂DS₂-VASc score, with higher scores indicating greater stroke risk 1
• Risk factors include congestive heart failure, hypertension, age ≥75 years (2 points), diabetes, prior stroke/TIA (2 points), vascular disease, age 65-74 years, and female sex 1
• No routine coagulation monitoring is required for patients on apixaban 1, 5
• Regular assessment of renal function, weight, and bleeding risk is important for maintaining appropriate dosing 3

By following these evidence-based recommendations for twice-daily dosing of apixaban in patients with atrial fibrillation, clinicians can effectively reduce the risk of stroke while minimizing bleeding complications.