Is a loading dose required for apixaban (generic name for Eliquis) initiation?

Loading Dose for Apixaban

No loading dose is required for apixaban initiation in any indication. Apixaban is started at the full therapeutic dose appropriate for the indication without any initial loading period 1.

Standard Dosing Regimens Without Loading

For Atrial Fibrillation (Stroke Prevention)

• Standard dose: 5 mg orally twice daily, started immediately without loading 1
• Reduced dose: 2.5 mg twice daily if patient has ≥2 of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 1
• Begin at the appropriate dose based on patient characteristics; no titration or loading phase is needed 2

For Venous Thromboembolism (DVT/PE Treatment)

• Initial 7 days: 10 mg orally twice daily 3, 1
• After 7 days: 5 mg orally twice daily 3, 1
• This higher initial dose for the first week serves as the treatment regimen, not a "loading dose" in the traditional sense—it is the standard therapeutic approach for acute VTE 3

For VTE Prophylaxis After Hip/Knee Surgery

• 2.5 mg orally twice daily starting 12-24 hours post-surgery 1
• No loading dose; begin at this maintenance dose immediately 1

For Extended VTE Prevention (After Initial Treatment)

• 2.5 mg orally twice daily after completing at least 6 months of treatment 1, 4
• Start at this dose without any loading period 4

Key Distinctions from Other Anticoagulants

Unlike dabigatran and edoxaban, apixaban does not require bridging with parenteral anticoagulation when initiating therapy 3. This is a critical advantage:

• Dabigatran and edoxaban: Require at least 5 days of LMWH or UFH before starting the oral agent 3
• Apixaban and rivaroxaban: Can be started immediately as monotherapy 3

Switching to Apixaban from Other Anticoagulants

When transitioning from other anticoagulants, no loading dose is used 1:

• From warfarin: Start apixaban when INR <2.0 1
• From other oral or parenteral anticoagulants: Discontinue the other agent and begin apixaban at the usual time of the next scheduled dose 1
• From LMWH or UFH: Start apixaban at the time the next dose of parenteral anticoagulant would have been given 1

Common Pitfalls to Avoid

• Do not use parenteral anticoagulation as a "bridge" when starting apixaban for atrial fibrillation or VTE treatment—this increases bleeding risk without benefit 3
• Do not double the first dose or use any form of loading strategy beyond the FDA-approved regimens 1
• For VTE treatment, the 10 mg twice daily for 7 days is the standard regimen, not an optional loading dose—failure to use this higher initial dose may compromise efficacy 3
• Do not confuse dose reduction criteria (age, weight, creatinine for atrial fibrillation) with the need for loading—reduced-dose patients still start at their appropriate dose immediately 1

Pharmacokinetic Rationale

Apixaban reaches steady-state concentrations by day 3 of therapy with an accumulation index of 1.3-1.9, achieving therapeutic anticoagulation rapidly without requiring a loading dose 5. Peak plasma concentration occurs approximately 3 hours post-dose, providing quick onset of anticoagulant effect 5.