What is the recommended dose of Eliquis (apixaban) for a 70-year-old patient with moderate renal impairment due to a creatinine level of 2.3 for the treatment of deep vein thrombosis (DVT)?

Apixaban Dosing for Brachial DVT in a 70-Year-Old with Creatinine 2.3

For this 70-year-old patient with brachial DVT and a creatinine of 2.3 mg/dL, start apixaban 10 mg twice daily for 7 days, then reduce to 5 mg twice daily for continued treatment. 1

Initial Treatment Phase (First 7 Days)

• Apixaban 10 mg orally twice daily is the FDA-approved dose for acute DVT treatment during the first week, regardless of renal function at this level 1
• This loading dose applies to all anatomic locations of DVT, including upper extremity (brachial) thrombosis 1
• No dose reduction is required during the initial 7-day treatment phase based on the creatinine level of 2.3 mg/dL alone 1

Maintenance Treatment Phase (After Day 7)

• Reduce to apixaban 5 mg twice daily after completing the 7-day loading phase 1
• This standard maintenance dose is appropriate because the patient does not meet the dose-reduction criteria for DVT treatment 1

Critical Dose-Reduction Assessment

The dose-reduction criteria (age ≥80 years, weight ≤60 kg, creatinine ≥1.5 mg/dL) apply ONLY to atrial fibrillation, NOT to DVT treatment 2, 1

• For DVT/PE treatment, the FDA label specifies no pre-specified dose-reduction criteria 3, 1
• Even though this patient has a creatinine of 2.3 mg/dL (meeting one criterion) and is 70 years old (not meeting the age criterion), these factors do not trigger dose reduction for DVT treatment 1
• The European guidelines confirm that apixaban for VTE treatment has "no dose reduction" in the maintenance phase 3

Renal Function Considerations

Calculate creatinine clearance using the Cockcroft-Gault equation to fully assess renal function 2

• A serum creatinine of 2.3 mg/dL likely corresponds to moderate-to-severe renal impairment (estimated CrCl 20-40 mL/min depending on weight and sex) 4
• Apixaban has only 27% renal excretion, making it relatively safer in renal impairment compared to other DOACs 2
• Post-hoc analysis from ARISTOTLE showed that apixaban caused less major bleeding than warfarin even in patients with CrCl 25-30 mL/min (HR 0.34,95% CI 0.14-0.80) 4
• The pharmacokinetic data demonstrate substantial overlap in apixaban exposure between patients with CrCl 25-30 mL/min and those with CrCl >30 mL/min, supporting standard dosing 4

Safety Profile in Renal Impairment

• Research demonstrates that apixaban maintains equivalent efficacy and superior safety compared to warfarin in patients with advanced CKD (stages 4-5) 5
• Among patients with isolated renal dysfunction receiving apixaban 5 mg twice daily, the benefit for major bleeding reduction (HR 0.68-0.72) was consistent regardless of renal function 6
• The median steady-state area under the curve for apixaban 5 mg twice daily in patients with CrCl 25-30 mL/min (5512 ng/mL·h) falls within the therapeutic range observed in patients with better renal function 4

Monitoring and Follow-Up

• Reassess renal function at least annually, and more frequently if clinical deterioration occurs 2
• No routine anticoagulation monitoring (INR) is required with apixaban 2
• Monitor for signs of bleeding, particularly given the moderate renal impairment 5
• If renal function worsens to CrCl <15 mL/min or dialysis is initiated, consider switching to warfarin or continuing apixaban with close monitoring, as data in dialysis patients are limited but emerging 5, 4

Common Pitfalls to Avoid

• Do not apply atrial fibrillation dose-reduction criteria to DVT treatment - this is the most common dosing error 1, 7
• Do not reduce the initial 10 mg twice daily dose during the first 7 days based on renal function alone 1
• Do not use the 2.5 mg twice daily dose for acute DVT treatment; this dose is reserved only for extended secondary prevention after at least 6 months of treatment 1
• Avoid bridging with LMWH, as apixaban does not require parenteral lead-in for DVT treatment 1

Duration of Therapy

• Continue the 5 mg twice daily maintenance dose for a minimum of 3 months for provoked DVT 8
• After completing at least 6 months of treatment, consider reducing to 2.5 mg twice daily for extended secondary prevention if long-term anticoagulation is indicated 1