What is the standard dosing regimen for Eliquis (apixaban) management?

Apixaban (Eliquis) Dosing Management

For atrial fibrillation, the standard dose of apixaban is 5 mg twice daily, with dose reduction to 2.5 mg twice daily ONLY when at least 2 of the following 3 criteria are present: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL (133 μmol/L). 1, 2

Standard Dosing by Indication

Atrial Fibrillation (Stroke Prevention)

• Standard dose: 5 mg orally twice daily 1, 2
• Reduced dose: 2.5 mg orally twice daily ONLY if ≥2 of these criteria are met: 1, 2
  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL

Critical point: Patients with only 1 dose-reduction criterion should receive the full 5 mg twice daily dose, as they demonstrate consistent efficacy and safety with standard dosing compared to warfarin. 3, 4 Underdosing with 2.5 mg twice daily when only 1 criterion is present risks inadequate stroke prevention. 1

Venous Thromboembolism (DVT/PE)

Acute treatment phase: 2

• 10 mg orally twice daily for first 7 days
• Then 5 mg orally twice daily for completion of treatment (minimum 6 months)

Extended secondary prevention: 1, 2

• 2.5 mg orally twice daily after completing at least 6 months of anticoagulation

Post-Surgical Thromboprophylaxis

• Hip replacement: 2.5 mg twice daily for 35 days, starting 12-24 hours post-surgery 2
• Knee replacement: 2.5 mg twice daily for 12 days, starting 12-24 hours post-surgery 2

Renal Function Adjustments

Atrial Fibrillation Dosing by Creatinine Clearance

• CrCl >50 mL/min: Standard dosing (5 mg or 2.5 mg twice daily based on dose-reduction criteria) 1
• CrCl 31-50 mL/min: Standard dosing (5 mg or 2.5 mg twice daily based on dose-reduction criteria) 1
• CrCl 15-30 mL/min: Standard dosing (5 mg or 2.5 mg twice daily based on dose-reduction criteria) 1
• End-stage renal disease on hemodialysis: 5 mg twice daily, reduced to 2.5 mg twice daily ONLY if age ≥80 years OR body weight ≤60 kg 1

Important caveat: Unlike other DOACs, apixaban does NOT require dose reduction based solely on renal function for atrial fibrillation. 1 The dose-reduction criteria remain age, weight, and creatinine level—not creatinine clearance. 1, 2

Drug Interactions Requiring Dose Adjustment

Combined P-glycoprotein and strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir): 2

• If receiving 5 mg or 10 mg twice daily: Reduce dose by 50%
• If already receiving 2.5 mg twice daily: Avoid coadministration 2

Strong dual P-gp/CYP3A4 inducers (rifampin, carbamazepine, phenytoin, St. John's wort): 1

• Avoid concomitant use as they significantly reduce apixaban levels 1

Monitoring Requirements

• Renal function: Assess before initiation and at least annually, or when clinically indicated 1, 5
• Use Cockcroft-Gault method for creatinine clearance calculation 1, 5
• Reassess body weight and renal function periodically, as changes may affect dose-reduction criteria status 5

Perioperative Management

Discontinuation timing before surgery: 1

• Low bleeding risk procedures: Hold for 1 full day (24 hours) before surgery
• High bleeding risk procedures: Hold for 2 full days (48 hours) before surgery

Resumption: Restart as soon as adequate hemostasis is established 2

Bridging: Not generally required during the 24-48 hour interruption period 2

Switching Between Anticoagulants

From warfarin to apixaban: 2

• Discontinue warfarin and start apixaban when INR <2.0

From apixaban to warfarin: 2

• Discontinue apixaban and begin both parenteral anticoagulant and warfarin at the time of next apixaban dose
• Discontinue parenteral anticoagulant when INR reaches therapeutic range

From/to other oral anticoagulants: 2

• Simply switch at the time of the next scheduled dose

Common Pitfalls to Avoid

Inappropriate dose reduction is extremely common and dangerous. 6, 7 Studies show that approximately 43% of patients receiving reduced-dose apixaban do not meet the required ≥2 dose-reduction criteria. 6 This underdosing increases thromboembolic risk without additional bleeding benefit. 1

Do NOT reduce dose based on: 1, 3

• Age 75-79 years alone
• Single dose-reduction criterion
• "Frailty" or "bleeding concern" without meeting specific criteria
• Concomitant antiplatelet therapy (instead, discontinue the antiplatelet) 1

Cancer patients with gastric/gastroesophageal tumors: Apixaban may be safer than rivaroxaban or edoxaban for these patients, though still carries hemorrhage risk. 1