Therapeutic Dosing for Eliquis (Apixaban)
Standard Dosing by Indication
Atrial Fibrillation (Stroke Prevention)
The standard dose is 5 mg orally twice daily for most patients with nonvalvular atrial fibrillation. 1
Dose reduction to 2.5 mg twice daily is required when patients meet at least TWO of the following three criteria: 2, 3, 1
- Age ≥80 years
- Body weight ≤60 kg
- Serum creatinine ≥1.5 mg/dL (133 μmol/L)
This dose reduction strategy is critical—underdosing patients who don't meet these criteria increases thromboembolic risk, while overdosing those who do meet criteria increases bleeding risk. 2 The ARISTOTLE trial demonstrated that properly dosed apixaban reduced stroke/systemic embolism by 21%, major bleeding by 31%, and all-cause mortality by 11% compared to warfarin. 4
Deep Vein Thrombosis and Pulmonary Embolism (Treatment)
For acute DVT/PE treatment, the dose is 10 mg orally twice daily for the first 7 days, then 5 mg twice daily thereafter. 3, 1
DVT/PE Prophylaxis After Orthopedic Surgery
The dose is 2.5 mg orally twice daily, starting 12-24 hours after surgery. 1
Recurrent DVT/PE Prevention
After completing at least 6 months of treatment for DVT/PE, the dose is 2.5 mg orally twice daily for extended prophylaxis. 1
Special Populations
Renal Impairment
No dose adjustment is needed for creatinine clearance >30 mL/min unless the patient meets the two-out-of-three dose reduction criteria listed above. 3, 4
For end-stage renal disease on hemodialysis: Use 5 mg twice daily, reduced to 2.5 mg twice daily only if age ≥80 years OR body weight ≤60 kg. 2, 4 Note that apixaban is preferred over dabigatran, rivaroxaban, or edoxaban in ESKD patients. 2
Critical Dosing Errors to Avoid
Common pitfall: Approximately 43% of patients receiving reduced-dose apixaban in clinical practice do not actually meet dose reduction criteria—this represents inappropriate underdosing that increases stroke risk. 5 Always verify that patients meet at least TWO of the three criteria before reducing the dose.
Renal function calculation: Use the Cockcroft-Gault formula with actual body weight to calculate creatinine clearance, NOT estimated GFR. 6 This is a frequent source of dosing errors.
No dose adjustment needed for obesity: Patients with BMI >40 do not require dose adjustment. 6
Drug Interactions Requiring Dose Modification
Avoid apixaban entirely with strong dual inhibitors of both CYP3A4 AND P-glycoprotein: ketoconazole, itraconazole, ritonavir, clarithromycin. 6, 1 If unavoidable, consider alternative anticoagulation.
Exercise caution with antiplatelet agents or NSAIDs: These significantly increase bleeding risk and should generally be discontinued when starting apixaban. 2, 6
Perioperative Management
For low bleeding risk procedures: Stop apixaban 24 hours before surgery (48 hours if CrCl 30-50 mL/min). 4, 1
For moderate-to-high bleeding risk procedures: Stop apixaban 48 hours before surgery (72 hours if CrCl 30-50 mL/min). 4, 1
For high hemorrhagic risk procedures (e.g., neurosurgery): Consider stopping 3-5 days before the procedure. 3
Bridging anticoagulation is NOT generally required during the 24-48 hour interruption period. 1 Resume apixaban as soon as adequate hemostasis is established postoperatively. 1
Administration and Adherence
Strict adherence is critical: Apixaban has a rapid offset of action (half-life ~12 hours), so missing even a single dose creates a period without thromboembolic protection. 4, 7
If a dose is missed: Take it as soon as remembered on the same day, then resume the twice-daily schedule. Never double the dose. 1
Food does not affect absorption: Apixaban can be taken with or without food. 7