What is the recommended dose of Eliquis (apixaban) for pulmonary embolism (PE)?

Eliquis (Apixaban) Dosing for Pulmonary Embolism

For acute pulmonary embolism treatment, start apixaban at 10 mg orally twice daily for the first 7 days, then reduce to 5 mg twice daily for at least 3 months. 1

Initial Treatment Phase (Days 1-7)

• Apixaban 10 mg orally twice daily for 7 days is the FDA-approved regimen for acute PE treatment 1
• No initial parenteral anticoagulation (heparin or enoxaparin) is required before starting apixaban, unlike dabigatran or edoxaban 2
• Treatment can be initiated immediately upon PE diagnosis 3
• This higher initial dose ensures rapid therapeutic anticoagulation during the acute phase 3

Maintenance Phase (After Day 7)

• Reduce to 5 mg orally twice daily after completing the 7-day initial phase 1
• Continue this maintenance dose for at least 3 months 2, 3
• For unprovoked PE or ongoing risk factors, extended anticoagulation beyond 3 months should be considered 3

Extended Secondary Prevention (After 6 Months)

• After completing at least 6 months of treatment, apixaban 2.5 mg twice daily can be used for extended prevention of recurrent VTE 1
• This reduced dose is specifically for long-term secondary prevention, not acute treatment 3

Dose Adjustments for Special Populations

Renal Impairment

• Use with caution if creatinine clearance <30 mL/min 3
• Severe renal impairment (CrCl <15 mL/min) was excluded from clinical trials 2

Drug Interactions

• Reduce dose by 50% when coadministered with combined P-glycoprotein and strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir) if taking 5 mg or 10 mg twice daily 1
• Avoid coadministration with these inhibitors if already taking 2.5 mg twice daily 1

Clinical Evidence Supporting This Regimen

• The AMPLIFY trial demonstrated that apixaban 10 mg twice daily for 7 days followed by 5 mg twice daily was non-inferior to enoxaparin/warfarin for preventing recurrent VTE (2.3% vs 2.7%) 2
• Major bleeding was significantly lower with apixaban (0.6%) compared to conventional therapy (1.8%), with superiority demonstrated (P<0.001) 2
• The composite of major bleeding and clinically relevant non-major bleeding was markedly reduced with apixaban (4.3% vs 9.7%) 2

Critical Pitfalls to Avoid

• Do not administer loading doses of parenteral anticoagulants when initiating apixaban, as this increases bleeding risk without added benefit 3
• Do not continue the 10 mg twice daily dose beyond 7 days for acute treatment—this is a common error that increases bleeding risk 3
• Do not double the dose if a dose is missed; take the missed dose as soon as possible on the same day and resume the twice-daily schedule 1
• Do not use the 2.5 mg twice daily dose for acute PE treatment—this dose is only for extended secondary prevention after completing at least 6 months of standard therapy 1

Advantages Over Traditional Therapy

• No routine coagulation monitoring required, unlike warfarin 3
• More predictable anticoagulant effect compared to warfarin 3
• Preferred over warfarin by the CHEST guidelines due to less bleeding and greater convenience 2

Cancer-Associated PE

• For patients with cancer-associated PE, LMWH is preferred over apixaban for the first 3 months of treatment 2
• Only 2.7% of patients in the AMPLIFY trial had cancer, limiting evidence in this population 2