What is the therapeutic dosage of Eliquis (apixaban) for deep vein thrombosis (DVT)?

Therapeutic Dosage of Eliquis (Apixaban) for DVT

For acute DVT treatment, start apixaban at 10 mg orally twice daily for 7 days, then reduce to 5 mg orally twice daily for at least 3 months, with no requirement for initial parenteral anticoagulation. 1

Initial Treatment Phase (Days 1-7)

• Administer 10 mg orally twice daily for the first 7 days as the loading dose regimen to achieve rapid anticoagulation 2, 1
• This loading dose was validated in the AMPLIFY trial, demonstrating non-inferiority to conventional enoxaparin/warfarin therapy with significantly lower major bleeding rates (0.6% vs 1.8%) 2, 3
• Unlike dabigatran and edoxaban, apixaban does not require initial parenteral anticoagulation (heparin or LMWH) before starting therapy 2, 1

Maintenance Phase (After Day 7)

• Transition to 5 mg orally twice daily after completing the 7-day loading dose 2, 1
• Continue this maintenance dose for at least 3 months for provoked DVT 3, 1
• For unprovoked DVT or patients with ongoing risk factors, consider extending treatment beyond 3 months 2, 3

Extended Treatment Phase (After 6 Months)

• For patients requiring anticoagulation beyond 6 months for secondary prevention, reduce to 2.5 mg orally twice daily 3, 1
• This reduced dose minimizes bleeding risk while maintaining efficacy for preventing recurrent DVT 3, 4
• The 2.5 mg twice daily regimen should be initiated after at least 6 months of treatment for DVT 1

Special Populations and Dose Adjustments

Renal Impairment

• Avoid apixaban in severe renal impairment (CrCl <15 mL/min) 3
• Use with caution if CrCl <25 mL/min 3
• No specific dose reduction is required for the DVT treatment indication based on renal function alone 1

Hepatic Impairment

• Avoid in significant hepatic impairment (transaminases >2x upper limit of normal or total bilirubin >1.5x upper limit of normal) 3

Drug Interactions

• When coadministered with combined P-glycoprotein and strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir), reduce the dose by 50% for patients receiving 5 mg or 10 mg twice daily 1
• In patients already taking 2.5 mg twice daily, avoid coadministration with these inhibitors 1

Cancer-Associated DVT

• Apixaban is a viable option for cancer-associated DVT, showing non-inferiority to dalteparin 2, 3, 4
• Use the same dosing regimen (10 mg twice daily for 7 days, then 5 mg twice daily) 2
• However, exercise caution in patients with gastric or gastroesophageal tumors due to increased hemorrhage risk, though apixaban may be safer than edoxaban or rivaroxaban in this population 2

Critical Caveats

Missed Dose Management

• If a dose is missed, take it as soon as possible on the same day and resume twice-daily administration 1
• Never double the dose to make up for a missed dose 1

Surgical Interruption

• Discontinue apixaban at least 48 hours prior to elective surgery or invasive procedures with moderate or high bleeding risk 1
• Discontinue at least 24 hours prior for procedures with low bleeding risk 1
• Bridging anticoagulation during the 24-48 hours after stopping apixaban is not generally required 1

Parenteral Anticoagulation Overlap

• A recent study found that patients who received initial parenteral anticoagulation followed by shortened apixaban lead-in therapy (<7 days) had higher bleeding rates (18.5% vs 5.1%) compared to the standard 7-day lead-in 5
• Avoid shortening the 7-day loading dose regimen, even if parenteral anticoagulation was given initially, unless bleeding risk factors necessitate it 5

Administration for Patients Unable to Swallow

• Tablets can be crushed and suspended in water or administered via nasogastric tube for patients unable to swallow whole tablets 1