What is the appropriate dosing of Eliquis (apixaban) for patients over 80 years old with deep vein thrombosis (DVT), comparing low dose to full dose?

From the Guidelines

For patients over 80 years old with deep vein thrombosis (DVT), the dosing of Eliquis (apixaban) should be considered on a case-by-case basis, taking into account the patient's individual risk factors, with the option to use either the standard dose or the lower dose of 2.5 mg twice daily, as suggested by the American Society of Hematology 2020 guidelines 1. When considering the management of DVT in patients over 80, it's crucial to weigh the risks of bleeding against the benefits of anticoagulation. The standard initial treatment for acute DVT is 10 mg twice daily for 7 days, followed by 5 mg twice daily, regardless of age, as indicated in the guidelines from the French Working Group on Perioperative Hemostasis (GIHP) 1. However, for long-term prevention of VTE, a reduced dose of 2.5 mg twice daily may be considered for patients with specific risk factors such as low body weight (≤60 kg) or impaired kidney function, as these factors can increase the risk of bleeding. Key considerations in the management of DVT in elderly patients include:

• Monitoring kidney function regularly, as declining renal function may necessitate dose adjustments
• Assessing the patient's overall risk of bleeding and recurrence of VTE
• Individualizing the treatment plan based on the patient's specific risk factors and medical history
• Consulting with a healthcare provider before making any changes to the medication regimen, as individual factors may influence the appropriate dosing strategy. The American Society of Hematology 2020 guidelines suggest that the decision to use the standard dose or the lower dose of apixaban should be based on the individual patient's risk factors and medical history, with a conditional recommendation for either dose for the secondary prevention of VTE 1.

From the FDA Drug Label

2.1 Recommended Dose ... The recommended dose of apixaban tablets for most patients is 5 mg taken orally twice daily. The recommended dose of apixaban tablets is 2.5 mg twice daily in patients with at least two of the following characteristics:

• age greater than or equal to 80 years
• body weight less than or equal to 60 kg
• serum creatinine greater than or equal to 1.5 mg/dL ... 1.3 Treatment of Deep Vein Thrombosis Apixaban tablets are indicated for the treatment of DVT. 2.1 ... Treatment of DVT and PE The recommended dose of apixaban tablets is 10 mg taken orally twice daily for the first 7 days of therapy. After 7 days, the recommended dose is 5 mg taken orally twice daily.

For patients over 80 years old with DVT, the dose of Eliquis (apixaban) is 2.5 mg twice daily if they have at least two of the specified characteristics, but for treatment of DVT, the recommended dose is 10 mg twice daily for the first 7 days, then 5 mg twice daily. However, for patients with at least two of the following characteristics: age ≥ 80 years, body weight ≤ 60 kg, or serum creatinine ≥ 1.5 mg/dL, a lower dose of 2.5 mg twice daily is recommended for the reduction in the risk of recurrence of DVT [see Clinical Studies (14.3)] 2.

• Key points:
  • Age ≥ 80 years is one of the characteristics that may require a dose adjustment.
  • DVT treatment dose is 10 mg twice daily for the first 7 days, then 5 mg twice daily.
  • Lower dose of 2.5 mg twice daily may be recommended for patients with certain characteristics.

From the Research

Eliquis (Apixaban) Dosage for DVT in Patients Over 80

• The use of anticoagulants in patients over 80 years old with deep vein thrombosis (DVT) requires careful consideration of the balance between thromboembolic and bleeding risks 3, 4, 5.
• There is limited research specifically comparing low-dose and full-dose apixaban (Eliquis) in patients over 80 with DVT.
• A study on upper extremity DVT found that low-dose apixaban (2.5 mg twice daily) or rivaroxaban (10 mg daily) may be effective as secondary prophylaxis in patients with persistent thrombotic risk factors or without recanalization of the affected vein 6.
• The study found no thromboembolic events or hemorrhagic complications during treatment with low-dose DOACs, suggesting that dose reduction may be a viable option in certain patients 6.
• However, more research is needed to confirm these findings and establish the optimal dosage of apixaban for DVT in patients over 80.
• Other studies have compared the efficacy and safety of rivaroxaban versus warfarin in the management of unusual site DVT, finding that rivaroxaban exhibited comparable efficacy with a lower risk of bleeding complications and major bleeding 7.
• The recommendations for anticoagulation in patients over 80 years old are based on the thromboembolic/bleeding risk relation, and may involve the use of low-molecular-weight heparin (LMWH) or vitamin K antagonists, with careful monitoring and adjustment of therapy as needed 5.