What is the recommended dose of apixaban (a direct oral anticoagulant) for the treatment of pulmonary embolism?

Apixaban Dosing for Pulmonary Embolism Treatment

For pulmonary embolism treatment, apixaban should be administered at 10 mg twice daily for the first 7 days, followed by 5 mg twice daily for at least 3 months. 1, 2

Initial Treatment Phase

• Apixaban should be started at 10 mg twice daily for the first 7 days of therapy 1, 2
• No initial parenteral anticoagulation (such as heparin or enoxaparin) is required before starting apixaban, unlike some other direct oral anticoagulants 1
• Treatment can be initiated immediately upon diagnosis of pulmonary embolism, provided there are no contraindications 1

Maintenance Phase

• After the initial 7-day period, the dose should be reduced to 5 mg twice daily 1, 2
• Treatment should continue for at least 3 months 1
• For patients with unprovoked pulmonary embolism or ongoing risk factors, extended anticoagulation beyond 3 months may be necessary 1

Extended Treatment Phase

• For patients requiring extended treatment beyond the initial treatment period (after at least 6 months of treatment), the recommended dose is 2.5 mg twice daily 2
• Extended treatment with apixaban has been shown to significantly reduce the risk of recurrent venous thromboembolism compared to placebo 3

Efficacy and Safety Profile

• Apixaban has been shown to be non-inferior to conventional therapy (enoxaparin/warfarin) for the treatment of venous thromboembolism 4, 5
• Major bleeding occurs less frequently with apixaban (0.6%) compared to conventional therapy (1.8%) 4, 5
• The composite of major bleeding and clinically relevant non-major bleeding is significantly lower with apixaban (4.3%) compared to conventional therapy (9.7%) 4, 5

Special Considerations

Renal Function

• Use apixaban with caution in patients with severe renal impairment (creatinine clearance <30 mL/min) 1

Drug Interactions

• For patients receiving apixaban who require concomitant therapy with combined P-glycoprotein (P-gp) and strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, ritonavir):
  • Reduce the dose by 50% when apixaban is coadministered with these drugs 2
  • For patients already taking 2.5 mg twice daily, avoid coadministration with combined P-gp and strong CYP3A4 inhibitors 2

Temporary Interruption for Surgery

• Discontinue apixaban at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of significant bleeding 2
• Discontinue at least 24 hours prior to procedures with a low risk of bleeding 2
• Resume apixaban as soon as adequate hemostasis has been established 2

Common Pitfalls to Avoid

• Do not administer loading doses of parenteral anticoagulants when initiating apixaban, as this increases bleeding risk 1
• Do not continue the initial higher dose (10 mg twice daily) beyond the first 7 days 1, 2
• Do not double the dose to make up for a missed dose; if a dose is missed, take it as soon as possible on the same day and resume the normal twice-daily schedule 2
• Avoid abrupt discontinuation as this increases the risk of thrombotic events; if anticoagulation must be discontinued for reasons other than bleeding, consider transitioning to another anticoagulant 2