What is the difference between Eliquis (apixaban) 2.5mg and 5mg dosing?

How to Determine Apixaban (Eliquis) Dosing: 2.5 mg vs 5 mg

For atrial fibrillation, use 5 mg twice daily as the standard dose, but reduce to 2.5 mg twice daily only when the patient meets at least 2 of these 3 criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1, 2, 3

Standard Dosing Algorithm for Atrial Fibrillation

Step 1: Start with 5 mg twice daily as the default dose for most patients with nonvalvular atrial fibrillation 1, 4, 3

Step 2: Check for dose reduction criteria - count how many of the following apply:

• Age ≥80 years 1, 2, 3
• Body weight ≤60 kg 1, 2, 3
• Serum creatinine ≥1.5 mg/dL 1, 2, 3

Step 3: Apply the dosing decision:

• If 0 or 1 criterion present: Use 5 mg twice daily 1, 5
• If 2 or 3 criteria present: Reduce to 2.5 mg twice daily 1, 2, 3

Critical Point About Single Criterion

Patients with only ONE dose-reduction criterion should receive the full 5 mg twice daily dose. This is a common prescribing error - the ARISTOTLE trial demonstrated that patients with isolated advanced age, low body weight, or renal dysfunction show consistent benefits and safety with 5 mg twice daily compared to warfarin 5. The 5 mg dose remains appropriate and effective for these patients despite having one risk factor 5.

Renal Function Considerations

• For creatinine clearance >25 mL/min, follow the standard dosing algorithm above (5 mg or 2.5 mg based on the 2-out-of-3 criteria) 1
• For end-stage renal disease on hemodialysis, use 5 mg twice daily, reduced to 2.5 mg twice daily if age ≥80 years OR body weight ≤60 kg 4
• No dose adjustment is needed for creatinine clearance >30 mL/min unless other dose-reduction criteria are met 4

Alternative Indications with Different Dosing

For VTE treatment (DVT/PE):

• Initial 7 days: 10 mg twice daily 2, 3
• After 7 days: 5 mg twice daily for at least 6 months 2, 3

For VTE prophylaxis after hip/knee replacement:

• 2.5 mg twice daily 3

For prevention of recurrent VTE:

• 2.5 mg twice daily after completing at least 6 months of initial anticoagulation 2, 3

Common Prescribing Pitfalls

Avoid underdosing patients with single criteria: Approximately 43% of patients receiving reduced-dose apixaban in clinical practice do not meet the appropriate dose-reduction criteria 6. Patients with only one criterion (such as age 82 with normal weight and creatinine) should receive 5 mg twice daily, not 2.5 mg 5.

The "2-out-of-3 rule" is mandatory: Both criteria must be present simultaneously to justify dose reduction for atrial fibrillation 1, 2, 3. This differs from other DOACs which have different dose-reduction algorithms 1.

Comparative Efficacy Data

• Apixaban 5 mg twice daily demonstrated superiority over warfarin for stroke prevention (odds ratio 0.79) and major bleeding reduction (odds ratio 0.71) 7
• The reduced 2.5 mg twice daily dose (when appropriately prescribed) maintains favorable outcomes compared to warfarin without increased bleeding risk 6
• Network meta-analysis ranked apixaban 5 mg twice daily highest for most efficacy and safety outcomes among all DOACs 7