Eliquis (Apixaban) Dosing for Anticoagulation
The standard dose of apixaban is 5 mg orally twice daily for most indications, with dose reduction to 2.5 mg twice daily required when specific criteria are met. 1
Standard Dosing by Indication
Atrial Fibrillation (Stroke Prevention)
- Standard dose: 5 mg orally twice daily 2, 1
- Reduced dose: 2.5 mg twice daily when patient has at least 2 of the following criteria: 2, 1
- Age ≥80 years
- Body weight ≤60 kg
- Serum creatinine ≥1.5 mg/dL
- This dosing strategy reduces stroke/systemic embolism while maintaining favorable bleeding profiles compared to warfarin 3
Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Treatment
- Initial 7 days: 10 mg orally twice daily 2, 1
- After 7 days: 5 mg orally twice daily for continued treatment 2, 1
- Extended prevention (after ≥6 months initial therapy): 2.5 mg twice daily to reduce recurrence risk 1
VTE Prophylaxis After Hip or Knee Replacement
- Dose: 2.5 mg orally twice daily 2, 1
- Timing: Start 12-24 hours after surgery 1
- Duration: 2, 1
- Hip replacement: 35 days (5 weeks)
- Knee replacement: 12 days
Critical Dose Adjustments
Drug Interactions Requiring Dose Reduction
- When combined with dual P-gp AND strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir): 1
- If taking 5 mg or 10 mg twice daily: reduce dose by 50%
- If already taking 2.5 mg twice daily: avoid coadministration
- With strong CYP3A4 inhibitors alone (e.g., ceritinib): reduce dose by 50% 2
- With P-gp inhibitors alone: reduce dose by 25% (e.g., 5 mg twice daily → 5 mg morning and 2.5 mg afternoon) 2
End-Stage Renal Disease on Hemodialysis
- Standard dose: 5 mg twice daily 1
- Reduced dose: 2.5 mg twice daily if age ≥80 years OR body weight ≤60 kg 2, 1
- Note: This population has substantially higher bleeding risk (32% at 1 year) compared to stroke risk (3% at 1 year), requiring careful risk-benefit assessment 4
Perioperative Management
Elective Surgery Interruption
- Low bleeding risk procedures: Stop 24 hours before 1
- Moderate-high bleeding risk procedures: Stop 48 hours before 1
- Very high bleeding risk (neurosurgery, neuraxial anesthesia): Stop 3-5 days before if creatinine clearance >30 mL/min 2, 3
- Bridging anticoagulation is NOT generally required during the 24-48 hour interruption period 1
Resumption After Surgery
- Resume when adequate hemostasis established 1
- If immediate VTE prophylaxis needed: use heparin or fondaparinux at least 6 hours post-procedure, then transition to apixaban 2
Switching Between Anticoagulants
From Warfarin to Apixaban
- Stop warfarin and start apixaban when INR <2.0 1
From Apixaban to Warfarin
- Discontinue apixaban and start both parenteral anticoagulant AND warfarin at the time of next apixaban dose 1
- Continue parenteral anticoagulant until INR reaches therapeutic range 1
- Note: Apixaban affects INR measurements, making initial INR values unreliable for warfarin dosing 1
From/To Other Anticoagulants
- Simply switch at the time of the next scheduled dose without overlap 1
Common Pitfalls and Caveats
Inappropriate Dose Reduction
- 43% of patients receiving reduced-dose apixaban in clinical practice do NOT meet dose-reduction criteria 5
- Inappropriately reduced dosing may increase thrombotic risk without additional bleeding benefit 5
- Always verify that at least 2 of the 3 criteria are present before reducing to 2.5 mg twice daily 2, 1
Older Adults
- Apixaban concentrations in older adults are often higher than expected from clinical trial data, particularly in those receiving 2.5 mg twice daily 6
- One-third of older adults on 2.5 mg twice daily had concentrations exceeding expected peak levels 6
- Consider monitoring apixaban levels when dosing outside published guidelines or in patients differing substantially from trial populations 6
Neuraxial Anesthesia Risk
- Epidural or spinal hematomas can cause permanent paralysis 1
- Never perform neuraxial procedures with insufficient apixaban discontinuation time, especially in patients >80 years or with renal failure 2
- Monitor frequently for neurological impairment post-procedure 1
Premature Discontinuation
- Stopping apixaban without alternative anticoagulation increases thrombotic event risk 1
- If discontinuing for reasons other than bleeding or therapy completion, provide coverage with another anticoagulant 1