Criteria for Low-Dose Apixaban (Eliquis)
For atrial fibrillation, reduce apixaban from 5 mg twice daily to 2.5 mg twice daily only when the patient meets at least 2 of the following 3 criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL (or creatinine clearance 15-29 mL/min). 1, 2, 3
Dose Reduction Criteria for Atrial Fibrillation
The FDA-approved dose reduction requires at least 2 of 3 criteria to be present simultaneously: 3
Alternatively, creatinine clearance 15-29 mL/min alone qualifies for dose reduction to 2.5 mg twice daily. 1
Critical Implementation Points
Meeting only 1 criterion does NOT justify dose reduction - this is a common prescribing error that leads to underdosing. 2, 4 The patient must have at least 2 of the 3 criteria present to warrant the reduced dose. 3
For end-stage renal disease on hemodialysis, use 5 mg twice daily as standard dosing, reducing to 2.5 mg twice daily only if age ≥80 years OR body weight ≤60 kg (note: only 1 additional criterion needed in this specific population). 2
Renal Function Assessment
Calculate creatinine clearance using the Cockcroft-Gault formula before initiating therapy, as this is the method used in clinical trials and FDA approval. 2 Reassess renal function at least annually and whenever clinical deterioration occurs. 2
For creatinine clearance >30 mL/min without meeting the other dose-reduction criteria, use standard dosing of 5 mg twice daily. 2
Other Indications with Different Dosing
For VTE extended-phase therapy (secondary prevention after completing at least 6 months of treatment), use 2.5 mg twice daily regardless of the atrial fibrillation dose-reduction criteria. 2, 3
For post-orthopedic surgery prophylaxis, use 2.5 mg twice daily for all patients. 1, 3
For acute DVT/PE treatment, use 10 mg twice daily for 7 days, then 5 mg twice daily - no dose reduction applies during acute treatment phase. 1, 3
Common Pitfalls to Avoid
Inappropriate dose reduction occurs in approximately 43-57% of patients receiving reduced-dose apixaban, where providers reduce the dose based on clinical judgment rather than meeting the specified criteria. 4, 5 This practice lacks evidence-based support and may increase thromboembolic risk. 6
Age alone is not sufficient - an 85-year-old patient weighing 75 kg with normal renal function should receive 5 mg twice daily, not 2.5 mg twice daily. 2, 3
Single criterion dosing error - a patient with serum creatinine 1.6 mg/dL who is 75 years old and weighs 70 kg does NOT qualify for dose reduction because only 1 criterion is met. 3
Monitoring Requirements
Reassess body weight and renal function periodically, as changes may affect whether the patient meets dose-reduction criteria. 2 Patients initially on standard dosing may later qualify for dose reduction if they develop additional criteria (e.g., weight loss, declining renal function). 2
Monitor for bleeding complications, particularly gastrointestinal bleeding, which remains a risk even with appropriately reduced dosing. 7