How Eliquis (Apixaban) is Usually Prescribed
Eliquis is most commonly prescribed at 5 mg twice daily for atrial fibrillation, with dose reduction to 2.5 mg twice daily only when patients meet at least two of three specific criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1
Standard Dosing by Indication
Atrial Fibrillation (Stroke Prevention)
- Standard dose: 5 mg orally twice daily for most patients 2, 1
- Reduced dose: 2.5 mg orally twice daily only when patients have at least two of the following characteristics 2, 1:
- Age ≥80 years
- Body weight ≤60 kg
- Serum creatinine ≥1.5 mg/dL
Critical caveat: Patients with only ONE dose-reduction criterion should receive the full 5 mg twice daily dose, as they demonstrate consistent safety and efficacy at this dose compared to warfarin 3. Underdosing patients with isolated advanced age, low body weight, or renal dysfunction is inappropriate and not supported by evidence 3.
Venous Thromboembolism (VTE) Treatment
- Initial therapy (first 7 days): 10 mg orally twice daily 2, 1
- Continuation therapy (after 7 days): 5 mg orally twice daily 2, 1
- Extended secondary prevention (after ≥6 months): 2.5 mg orally twice daily can be considered 2, 1
Important note: Unlike dabigatran and edoxaban, apixaban does NOT require initial parenteral anticoagulation before starting oral therapy 2.
VTE Prophylaxis After Orthopedic Surgery
- Dose: 2.5 mg orally twice daily 2, 4, 1
- Timing: Initial dose 12-24 hours after surgery 1
- Duration: 35 days for hip replacement; 12 days for knee replacement 1
Renal Dosing Adjustments
For Atrial Fibrillation
- CrCl >50 mL/min: Standard dosing applies 2
- CrCl 15-50 mL/min: Use standard 5 mg twice daily unless patient also meets two dose-reduction criteria 2
- CrCl <15 mL/min: Avoid apixaban 4
For VTE Treatment
- No specific renal dose adjustments are required for VTE treatment dosing 2
- Apixaban has 27% renal excretion, making it more favorable in renal impairment compared to dabigatran (80% renal) or edoxaban (50% renal) 2
Special Clinical Scenarios
Cardioversion in Atrial Fibrillation
- For anticoagulation-naïve patients requiring immediate cardioversion, a single loading dose of 10 mg (or 5 mg if dose-reduced) may be administered 2, 5
- Standard dosing then continues as 5 mg or 2.5 mg twice daily based on dose-reduction criteria 2
- At least 3 weeks of anticoagulation is required before cardioversion if no transesophageal echocardiography is performed 2
Perioperative Management
- Discontinue 48 hours before elective surgery with moderate-to-high bleeding risk 1
- Discontinue 24 hours before procedures with low bleeding risk 1
- Resume apixaban after adequate hemostasis is established, typically 24-72 hours postoperatively for high-risk procedures 6
- For high-risk procedures like cervical spine surgery, resume the next day (not same day) for twice-daily regimens 6
Switching Between Anticoagulants
- From warfarin to apixaban: Start apixaban when INR <2.0 1
- From apixaban to warfarin: Discontinue apixaban and begin parenteral anticoagulant plus warfarin simultaneously; discontinue parenteral when INR is therapeutic 1
- From/to other DOACs: Simply switch at the time of the next scheduled dose 1
Common Prescribing Errors to Avoid
Inappropriate dose reduction is a significant problem in clinical practice. In the AUGUSTUS trial, only 43% of patients receiving reduced-dose apixaban actually met dose-reduction criteria 7. Patients with only one dose-reduction criterion who receive 2.5 mg twice daily are being underdosed and may have suboptimal stroke prevention 3.
Hepatic impairment considerations: Use with caution when transaminases >2× upper limit of normal or total bilirubin >1.5× upper limit of normal 4.
Drug interactions: Avoid concurrent use with combined P-glycoprotein and strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, ritonavir) in patients receiving 5 mg twice daily; reduce to 2.5 mg twice daily if such combinations are necessary 2. Avoid P-glycoprotein/CYP3A4 inducers (carbamazepine, phenytoin, rifampin, St. John's wort) as they significantly reduce apixaban levels 2.