What is the recommended dose and duration of Eliquis (apixaban) for Deep Vein Thrombosis (DVT) prophylaxis?

Apixaban for DVT Prophylaxis

For DVT prophylaxis after hip or knee replacement surgery, use apixaban 2.5 mg orally twice daily, starting 12-24 hours post-surgery, for 35 days after hip replacement or 12 days after knee replacement. 1

Dosing Regimen for Orthopedic Surgery Prophylaxis

• Initial dose timing: Begin apixaban 2.5 mg orally twice daily 12-24 hours after surgery 2, 1
• Duration for hip replacement: Continue for 35 days (or 28-35 days per some protocols) 2, 1
• Duration for knee replacement: Continue for 12 days (or 10-14 days per some protocols) 2, 1

Evidence Supporting This Regimen

The ADVANCE trial program demonstrated apixaban's superiority over enoxaparin for VTE prophylaxis:

• ADVANCE-2 (knee replacement): Apixaban showed superior efficacy compared to enoxaparin 40 mg daily (1.51% vs 24.4% VTE or mortality; RR 0.62, P<0.0001) 2
• ADVANCE-3 (hip replacement): Apixaban was superior to enoxaparin (1.4% vs 3.9%; RR 0.36, P<0.001) 2
• Bleeding rates: Numerically lower major or clinically relevant non-major bleeding with apixaban across all trials 2

Key Advantages Over Injectable Prophylaxis

• Oral administration: Eliminates need for daily subcutaneous injections, improving patient compliance 3
• Fixed dosing: No laboratory monitoring required 4
• Comparable safety: Similar or lower bleeding rates compared to enoxaparin 2, 3

Critical Contraindications and Precautions

Neuraxial Anesthesia Warning

Do not perform spinal or epidural anesthesia in patients with insufficient apixaban discontinuation time, particularly in patients over 80 years or with renal failure. 2, 1

• Epidural or spinal hematomas may cause permanent paralysis 1
• Risk factors include indwelling epidural catheters, concomitant NSAIDs/antiplatelet agents, and history of spinal procedures 1
• Monitor frequently for neurological impairment 1

Renal Impairment Adjustments

• CrCl <25 mL/min: Avoid use; patients excluded from clinical trials 4, 5
• CrCl <15 mL/min: Contraindicated 4, 5
• No dose adjustment needed for CrCl >30 mL/min in prophylaxis setting 2

Drug Interactions

• Contraindicated: Strong dual inhibitors of CYP3A4 and P-glycoprotein (ketoconazole, ritonavir) increase plasma concentrations 2
• Caution with: P-glycoprotein inhibitors may require dose consideration 2

Perioperative Management for Subsequent Procedures

If a patient on apixaban requires elective surgery:

• High bleeding risk procedures: Discontinue 3 days before surgery (CrCl >30 mL/min) 2
• Very high bleeding risk (neurosurgery, neuraxial procedures): Discontinue up to 5 days before 2
• Low bleeding risk: Discontinue 24 hours before 1
• Resumption: Restart when adequate hemostasis established, typically 6+ hours post-procedure 2, 1

Common Pitfalls to Avoid

• Premature discontinuation: Increases thrombotic event risk; if stopping apixaban, consider bridging with another anticoagulant 1
• Starting too early post-surgery: Wait minimum 12 hours to reduce bleeding risk 1
• Overlapping with heparin: No bridging needed when transitioning between anticoagulants 2
• Ignoring renal function: Always calculate CrCl using Cockcroft-Gault formula before prescribing 2

Comparison to Alternative Prophylaxis

Recent evidence confirms apixaban's effectiveness matches or exceeds enoxaparin:

• A 2021 study of 200 knee replacement patients found no significant differences in DVT incidence (1.5% in both groups) or wound complications between apixaban 2.5 mg twice daily and enoxaparin 4000 IU daily 3
• Oral administration provides practical advantage for outpatient continuation 3