What is the recommended dose of apixaban (apixaban) for a patient with impaired renal function (creatinine clearance of 59 mL/min)?

Apixaban Dosing with CrCl 59 mL/min

With a creatinine clearance of 59 mL/min, you should receive the standard dose of apixaban 5 mg twice daily, as you do not meet the criteria for dose reduction. 1, 2

Understanding the Dose Reduction Criteria

Apixaban dose reduction to 2.5 mg twice daily is only indicated when a patient meets at least 2 of the following 3 criteria 1, 2:

• Age ≥80 years
• Body weight ≤60 kg
• Serum creatinine ≥1.5 mg/dL (or ≥133 μmol/L)

Your CrCl of 59 mL/min alone does not trigger dose reduction. 1, 2 This represents mild-to-moderate renal impairment (CKD stage G2-G3a), which falls well above the threshold where renal function alone would necessitate dose adjustment. 3

Why This Dosing Is Appropriate

• Apixaban has minimal renal clearance (27%) compared to other direct oral anticoagulants like dabigatran (80%) or edoxaban (50%), making it particularly suitable for patients with renal impairment. 3, 1

• The ARISTOTLE trial specifically demonstrated that patients with only one dose-reduction criterion (such as isolated renal dysfunction in your range) who received 5 mg twice daily had similar efficacy and safety compared to those with no risk factors, with consistent benefit over warfarin. 4

• Patients with CrCl 25-30 mL/min (much lower than yours) safely received the standard 5 mg twice daily dose in clinical trials, showing even greater bleeding reduction compared to warfarin than patients with better renal function. 5

Common Dosing Errors to Avoid

The most frequent prescribing error with apixaban is underdosing (occurring in 9.4-40.4% of apixaban prescriptions), often because clinicians mistakenly reduce the dose based on a single criterion rather than requiring two criteria. 3

Do not reduce your dose based solely on:

• Renal function in the 30-60 mL/min range 1, 2
• Age <80 years alone 2
• Weight >60 kg alone 2
• Perceived bleeding risk without meeting formal criteria 3

When to Reassess

• Renal function should be rechecked at least annually, and more frequently if clinical deterioration occurs or acute illness develops. 2

• If your renal function declines to CrCl <30 mL/min AND you meet one additional criterion (age ≥80 or weight ≤60 kg), then dose reduction to 2.5 mg twice daily would be appropriate. 1, 2

• Calculate CrCl using the Cockcroft-Gault equation, not eGFR, as this is the validated method for DOAC dosing. 3, 2