Standard Dosing for Eliquis (Apixaban)
The standard dosing for Eliquis (apixaban) is 5 mg twice daily for most patients with nonvalvular atrial fibrillation, with a reduced dose of 2.5 mg twice daily for patients who meet specific dose-reduction criteria. 1
Standard Dosing Regimen
- For most patients with nonvalvular atrial fibrillation (AF), the recommended dose is 5 mg taken orally twice daily 1, 2
- For prophylaxis of deep vein thrombosis (DVT) following hip or knee replacement surgery, the recommended dose is 2.5 mg taken orally twice daily 1
- For treatment of DVT and pulmonary embolism (PE), the recommended dose is 10 mg taken orally twice daily for the first 7 days, followed by 5 mg taken orally twice daily 1
- For reduction in the risk of recurrence of DVT and PE after at least 6 months of treatment, the recommended dose is 2.5 mg taken orally twice daily 1
Dose Reduction Criteria
The dose should be reduced to 2.5 mg twice daily in patients with nonvalvular AF who have at least two of the following characteristics 1, 2:
- Age greater than or equal to 80 years
- Body weight less than or equal to 60 kg
- Serum creatinine greater than or equal to 1.5 mg/dL
Renal Dosing Considerations
- For patients with creatinine clearance >30 mL/min, no dose adjustment is needed 2
- 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
- The FDA-approved labeling does not provide specific dosage adjustments for patients with creatinine clearance 15-24 mL/min 2
Drug Interaction Considerations
- For patients receiving apixaban doses of 5 mg or 10 mg twice daily, reduce the dose by 50% when coadministered with drugs that are combined P-glycoprotein (P-gp) and strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, ritonavir) 1
- In patients already taking 2.5 mg twice daily, avoid coadministration with combined P-gp and strong CYP3A4 inhibitors 1
Perioperative Management
- Discontinue apixaban at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of significant bleeding 1
- Discontinue apixaban at least 24 hours prior to procedures with a low risk of bleeding 1
- Restart apixaban as soon as adequate hemostasis has been established 1
Clinical Considerations and Pitfalls
- Studies show that inappropriate dose reduction is common in clinical practice, with up to 60.8% of patients receiving reduced doses not meeting criteria for dose reduction 3
- Patients with one dose-reduction criterion (rather than two or more) should still receive the standard 5 mg twice daily dose, as clinical trials have shown consistent benefits compared to warfarin in these patients 4
- Patients with atrial fibrillation and advanced chronic kidney disease (CrCl 25-30 mL/min) showed less bleeding with apixaban compared to warfarin, supporting conventional dosing in this population 5
Missed Dose Management
- If a dose is missed, take it as soon as possible on the same day and resume twice-daily administration 1
- Do not double the dose to make up for a missed dose 1
Remember that proper dosing of apixaban is critical for balancing stroke prevention efficacy with bleeding risk. Inappropriate dose reduction may compromise stroke prevention efficacy, while failure to reduce the dose when indicated may increase bleeding risk.