Do we start apixaban (a direct oral anticoagulant) at 10mg?

Apixaban Initial Dosing

Yes, apixaban is started at 10 mg twice daily for the first 7 days when treating acute venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). 1, 2, 3

Context-Dependent Dosing

The 10 mg starting dose applies only to VTE treatment, not to other indications:

For VTE Treatment (DVT/PE):

• Days 1-7: 10 mg orally twice daily 1, 2, 3
• After Day 7: Reduce to 5 mg orally twice daily for continued treatment 1, 2, 3
• After 6 months: May reduce to 2.5 mg twice daily for extended secondary prevention 1, 2, 3

This loading dose regimen ensures rapid anticoagulation without requiring initial parenteral therapy, unlike dabigatran or edoxaban which mandate 5-10 days of heparin lead-in. 1, 2

For Atrial Fibrillation:

• Standard dose: 5 mg twice daily (no loading dose) 1, 3
• Reduced dose: 2.5 mg twice daily if patient meets ≥2 of the following criteria: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 1, 3

For Post-Surgical VTE Prophylaxis:

• Hip or knee replacement: 2.5 mg twice daily starting 12-24 hours post-surgery 3

Special Populations

Cancer-Associated VTE:

• The same 10 mg twice daily × 7 days loading dose applies, followed by 5 mg twice daily 1
• Apixaban is now a Grade 1A recommendation for cancer-associated thrombosis, upgraded from 1B based on trials including CARAVAGGIO and ADAM-VTE 1
• Caution: Patients with gastrointestinal or genitourinary malignancies may have higher bleeding risk with DOACs 1

Renal Impairment:

• No dose adjustment needed for VTE treatment even with moderate renal impairment (CrCl ≥30 mL/min) 3
• The 10 mg loading dose remains appropriate 3

Critical Pitfalls to Avoid

Do not confuse indications: The most common error is inappropriately using the 10 mg dose for atrial fibrillation or applying the 5 mg atrial fibrillation dose to acute VTE. 4 Real-world data shows 60.8% of patients receiving reduced-dose apixaban did not meet criteria for dose reduction, with prescribers inappropriately applying age, weight, and creatinine as individual factors rather than the specific combination criteria. 4

Do not use loading doses for cardioversion: While a single 10 mg loading dose was studied in the EMANATE trial for immediate cardioversion in anticoagulation-naïve atrial fibrillation patients, this is not part of official FDA labeling. 1, 5

Drug Interactions Requiring Dose Modification

When combining apixaban with both P-gp and strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, ritonavir): 3

• Reduce 10 mg twice daily to 5 mg twice daily 3
• Reduce 5 mg twice daily to 2.5 mg twice daily 3
• Avoid combined inhibitors entirely if patient already on 2.5 mg twice daily 3

For cancer patients on small-molecule inhibitors like ceritinib (strong CYP3A4 inhibitor), reduce apixaban dose by 50%. 1