Apixaban Dosing for Atrial Fibrillation
No, apixaban is NOT started at 10 mg twice daily for atrial fibrillation—the standard starting dose is 5 mg twice daily, with 10 mg twice daily reserved exclusively for the first 7 days of acute DVT/PE treatment. 1
Standard Dosing for Atrial Fibrillation
For most patients with nonvalvular atrial fibrillation, start apixaban at 5 mg orally twice daily with no loading dose required. 2, 3, 1
- This dosing was established in the ARISTOTLE trial (n=18,201), which demonstrated a 21% reduction in stroke/systemic embolism (HR 0.79,95% CI 0.66-0.95) and 31% reduction in major bleeding compared to warfarin. 2, 3
- No bridging anticoagulation or initial higher dose is needed when starting apixaban for atrial fibrillation. 3
Dose Reduction Criteria
Reduce to 2.5 mg twice daily ONLY if the patient meets at least 2 of the following 3 criteria: 2, 1
- Age ≥80 years
- Body weight ≤60 kg
- Serum creatinine ≥1.5 mg/dL
Common pitfall: Studies show that 43-61% of patients receiving reduced dose apixaban in clinical practice do not actually meet dose-reduction criteria, leading to inappropriate underdosing. 4, 5 The three dose-reduction factors (age, weight, creatinine) are often misapplied individually rather than requiring 2 of 3 criteria. 4
When 10 mg Twice Daily IS Used
The 10 mg twice daily dose is ONLY indicated for acute DVT/PE treatment during the first 7 days of therapy, then reduced to 5 mg twice daily. 1
- This higher dose is never used for atrial fibrillation stroke prevention. 1
- After completing the 7-day loading period for DVT/PE, continue 5 mg twice daily for treatment, or 2.5 mg twice daily for extended secondary prevention after at least 6 months of treatment. 1
Renal Function Considerations
Apixaban can be used across a wide range of renal function with the same dosing algorithm: 2, 3
- CrCl >25 mL/min: Apply standard dosing (5 mg twice daily) or dose reduction criteria (2.5 mg twice daily if ≥2 criteria met). 2
- CrCl 15-30 mL/min: Same dosing algorithm applies. 2
- End-stage renal disease on hemodialysis: Start 5 mg twice daily, reduce to 2.5 mg twice daily only if age ≥80 years OR body weight ≤60 kg. 3
- CrCl <15 mL/min not on dialysis: Contraindicated. 2, 3
The dose reduction criteria for renal impairment in AF differs from other DOACs—apixaban uses serum creatinine ≥1.5 mg/dL as one of three criteria (requiring 2 of 3), not creatinine clearance cutoffs alone. 2, 1