What dose adjustments are needed for Eliquis (apixaban) and Lexapro (escitalopram) with mild impaired renal function, given an estimated creatinine clearance (eCrCl) of 62 and a serum creatinine level of 0.91?

Apixaban and Escitalopram Dosing with Mild Renal Impairment

With a creatinine clearance of 62 mL/min and serum creatinine of 0.91, you should continue standard-dose apixaban 5 mg twice daily (no dose reduction needed) and standard-dose escitalopram 10-20 mg daily (no adjustment required). 1, 2, 3

Apixaban Dosing Decision

Your renal function does not warrant dose reduction for apixaban. Here's the algorithmic approach:

Step 1: Assess Dose-Reduction Criteria

Apixaban requires dose reduction to 2.5 mg twice daily only when at least 2 of the following 3 criteria are met: 1, 4

• Age ≥80 years
• Body weight ≤60 kg
• Serum creatinine ≥1.5 mg/dL

Your serum creatinine of 0.91 mg/dL does NOT meet the threshold of ≥1.5 mg/dL. 1, 4

Step 2: Evaluate Renal Function Category

• Your eCrCl of 62 mL/min represents mild renal impairment (CKD stage G2), not moderate or severe impairment 2
• The European Heart Rhythm Association confirms that standard dosing of 5 mg twice daily is appropriate for patients with CrCl 50-79 mL/min 2
• Apixaban has only 27% renal clearance, making it particularly suitable for patients with declining renal function 1, 2

Step 3: Confirm Standard Dosing

Continue apixaban 5 mg twice daily. 1, 2, 4

The ARISTOTLE trial specifically demonstrated that patients with only one dose-reduction criterion (which you don't even meet) had similar efficacy and safety with the 5 mg twice daily dose compared to warfarin. 5 Underdosing apixaban based on a single criterion or perceived bleeding risk is a common prescribing error that should be avoided. 6, 7

Critical Pitfall to Avoid

Do not reduce apixaban dose based solely on your creatinine of 0.91 or eCrCl of 62. 1, 2 The most common prescribing error is inappropriately reducing apixaban to 2.5 mg twice daily when patients meet only one or zero dose-reduction criteria. 6 Your serum creatinine must be ≥1.5 mg/dL (not 0.91) AND you must meet at least one other criterion (age ≥80 or weight ≤60 kg) before dose reduction is indicated. 1, 4

Monitoring Requirements for Apixaban

With your eCrCl of 62 mL/min, you require: 2

• Annual renal function monitoring (since CrCl ≥60 mL/min)
• More frequent monitoring if you develop acute illness, infections, or acute heart failure
• Use the Cockcroft-Gault equation for calculating CrCl, not eGFR, as this was the method validated in clinical trials 1, 2

Escitalopram (Lexapro) Dosing Decision

No dose adjustment is needed for escitalopram with your renal function. 3

Renal Dosing for Escitalopram

• The FDA label states: "No dosage adjustment is necessary for patients with mild or moderate renal impairment" 3
• Escitalopram should be used with caution only in severe renal impairment (creatinine clearance <20 mL/min) 3
• In patients with mild to moderate renal impairment, oral clearance of citalopram (the parent compound) was reduced by only 17% compared to normal subjects 3

Standard Dosing Applies

• For major depressive disorder: 10 mg once daily initially, may increase to 20 mg after minimum of one week 3
• For generalized anxiety disorder: 10 mg once daily initially, may increase to 20 mg after minimum of one week 3
• Your eCrCl of 62 mL/min is well above the threshold requiring caution 3

Drug Interactions to Monitor

For Apixaban

Avoid or use caution with: 2

• Strong P-glycoprotein inhibitors: ketoconazole, itraconazole, verapamil (contraindicated)
• Moderate inhibitors requiring caution: amiodarone, dronedarone, quinidine, clarithromycin
• Drugs that decrease effectiveness: rifampicin, St. John's wort
• NSAIDs and COX-2 inhibitors: can worsen renal function and increase bleeding risk

For Escitalopram

• No significant CYP3A4 inhibitory effect at 20 mg dose 3
• Modest CYP2D6 inhibitory effect 3
• No clinically significant interaction between apixaban and escitalopram expected

Summary of Your Specific Situation

Apixaban: 5 mg twice daily (standard dose) 1, 2, 4

Escitalopram: 10-20 mg once daily (standard dose) 3

Monitoring: Annual renal function assessment, more frequently if acute illness develops 2