From the Guidelines
The Eliquis (apixaban) dose should be reduced to 2.5mg twice daily in patients with impaired renal function when two out of three criteria are met: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥133 mmol/L, as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1.
Key Considerations
- The decision to reduce the Eliquis dose should be made by a healthcare provider based on specific patient factors, including renal function, age, and body weight.
- Dose reduction may also be necessary for patients with severe renal impairment (creatinine clearance 15-29 mL/min).
- Patients taking certain medications that interact with Eliquis, such as strong dual inhibitors of CYP3A4 and P-gp, may require dose adjustments.
- Regular monitoring of kidney function and overall health status is essential for patients on Eliquis to ensure the dosage remains appropriate over time.
Important Factors to Consider
- Age: ≥80 years
- Body weight: ≤60 kg
- Serum creatinine: ≥133 mmol/L
- Renal impairment: creatinine clearance 15-29 mL/min
- Medication interactions: strong dual inhibitors of CYP3A4 and P-gp
Recommendations
- Never reduce the Eliquis dose without medical supervision, as improper dosing can increase risks of stroke or bleeding complications.
- If unusual bleeding, bruising, or other concerning symptoms occur while taking Eliquis, contact the healthcare provider immediately.
- The 2024 ESC guidelines provide the most up-to-date recommendations for dose reduction in patients with impaired renal function, and should be followed in clinical practice 1.
From the Research
Dose Reduction Criteria for Apixaban in Patients with Impaired Renal Function
- The standard dose of apixaban is 5 mg twice daily, but patients with at least 2 dose-reduction criteria (age ≥80 years, weight ≤60 kg, and creatinine level ≥1.5 mg/dL) receive a reduced dose of 2.5 mg twice daily 2.
- Patients with 1 dose-reduction criterion who received the 5 mg twice daily dose of apixaban had higher rates of stroke or systemic embolism and major bleeding compared to those with no dose-reduction criteria 2.
- A study found no difference in major bleeding events, any bleeding event, ischemic stroke, or venous thromboembosis between patients with chronic kidney disease stage 4 and 5 who received apixaban 5 mg twice daily versus 2.5 mg twice daily 3.
- The validity of alternative definitions for dose reduction criteria based on age and renal function alone has been examined, but patient weight is often not available in electronic health data 4.
- Apixaban trough concentrations were found to be significantly higher in patients with moderate renal impairment compared to those with normal renal function, suggesting that patients with moderately reduced renal function may require monitoring and possible dose reduction 5.
Considerations for Dose Reduction in Patients with Impaired Renal Function
- The international guidelines recommend using direct oral anticoagulants (DOACs) over vitamin K antagonists for anticoagulation long-term therapy in patients diagnosed with venous thromboembolism (VTE) and for stroke prevention in patients with non-valvular atrial fibrillation (AF) 6.
- Dose reductions of DOACs are recommended for patients with AF and renal impairment, low body weight, and concomitant use of interfering medications, but not for patients with VTE based on the same indications for AF patients 6.
- Observational studies and randomized control trials show that patients with AF are usually older, more often have chronic diseases, and more often are treated with several concomitant medications, potentially increasing their hemorrhagic risk 6.