What is the recommended dosing regimen for apixaban (Apixaban) for the management of pulmonary embolism (PE)?

Apixaban Dosing for Pulmonary Embolism

For acute pulmonary embolism, initiate apixaban at 10 mg orally twice daily for exactly 7 days, then reduce to 5 mg twice daily for at least 3 months of total treatment. 1, 2

Initial Treatment Phase (Days 1-7)

• Start with 10 mg twice daily for the first 7 days without any preceding parenteral anticoagulation (no heparin or enoxaparin bridge required). 1, 2
• This higher initial dose provides rapid therapeutic anticoagulation during the acute phase when thrombotic risk is highest. 3
• Treatment can begin immediately upon PE diagnosis if no contraindications exist. 3

Maintenance Phase (Day 8 onwards)

• After completing 7 days, reduce to 5 mg twice daily for the remainder of treatment. 1, 2
• Continue this maintenance dose for a minimum of 3 months total treatment duration. 1, 3
• For unprovoked PE or ongoing risk factors, extended anticoagulation beyond 3 months should be considered. 3

Extended Secondary Prevention (After 6 months)

• If continuing anticoagulation beyond 6 months for recurrence prevention, reduce to 2.5 mg twice daily. 2
• This reduced-intensity regimen is specifically for long-term secondary prevention after completing initial treatment. 3

Special Populations

Renal Impairment

• Use with caution if creatinine clearance <30 mL/min. 3
• No routine dose adjustment needed for mild-moderate renal impairment during acute PE treatment. 2

Elderly or Low Body Weight

• The standard PE dosing regimen (10 mg twice daily × 7 days, then 5 mg twice daily) applies regardless of age ≥80 years or weight ≤60 kg. 2
• The 2.5 mg twice daily dose reduction criteria (age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL) apply only to atrial fibrillation, not PE treatment. 2

Critical Pitfalls to Avoid

• Never administer parenteral anticoagulation before starting apixaban for PE—this increases bleeding risk without added benefit. 3
• Do not continue the 10 mg twice daily dose beyond 7 days—this significantly increases major bleeding risk (0.6% with proper dosing vs 1.8% with conventional therapy). 1, 4
• Do not double doses if one is missed—simply take the next scheduled dose. 2
• Avoid shortened lead-in therapy duration if using parenteral anticoagulation first, as this increases bleeding events (18.5% vs 5.1% with full 7-day lead-in). 5

Efficacy and Safety Profile

• Apixaban demonstrates non-inferiority to enoxaparin/warfarin for preventing recurrent VTE (2.3% vs 2.7%). 4
• Major bleeding occurs significantly less frequently with apixaban (0.6%) compared to conventional therapy (1.8%), representing a 69% relative risk reduction. 1, 4
• The composite of major plus clinically relevant non-major bleeding is markedly lower with apixaban (4.3% vs 9.7%). 1, 4
• Real-world data confirm 27-39% lower major bleeding risk and 25-39% lower recurrent VTE risk compared to warfarin across all time points and PE subgroups. 6

Perioperative Management

• Discontinue apixaban at least 48 hours before elective surgery with moderate-to-high bleeding risk. 2
• Discontinue at least 24 hours before procedures with low bleeding risk. 2
• Bridging anticoagulation during the interruption period is not generally required. 2
• Restart apixaban when adequate hemostasis is established post-procedure. 2

Cancer-Associated PE

• While apixaban shows non-inferiority to dalteparin for cancer-associated VTE (5.6% vs 7.9% recurrence), 7 current guidelines suggest LMWH over apixaban for the first 3 months in cancer patients. 1
• The evidence base for apixaban in cancer-associated PE remains limited compared to LMWH. 1