Apixaban (Eliquis) Dosing for Nonvalvular Atrial Fibrillation
Standard Dosing Recommendation
The recommended dose of apixaban for most patients with nonvalvular atrial fibrillation is 5 mg orally twice daily. 1
This standard dose has demonstrated superior efficacy compared to warfarin, reducing stroke or systemic embolism by 21% (HR 0.79,95% CI 0.66-0.95) and major bleeding by 31% in the ARISTOTLE trial. 2, 3
Dose Reduction Criteria
Reduce the dose to 2.5 mg twice daily ONLY if the patient meets at least TWO of the following criteria: 1
- Age ≥80 years
- Body weight ≤60 kg
- Serum creatinine ≥1.5 mg/dL
Meeting only one criterion does NOT justify dose reduction—these patients should receive the standard 5 mg twice daily dose. 2, 4
Critical Dosing Pitfalls
Underdosing patients who meet only one dose-reduction criterion is a common error that increases thromboembolic risk without improving safety. 2, 5
- Patients with isolated advanced age, low body weight, or renal dysfunction show consistent benefits with 5 mg twice daily compared to warfarin, with similar safety profiles to those without these characteristics. 4
- Studies show that 12-21% of apixaban prescriptions are inappropriately underdosed, most commonly in elderly patients who meet only the age criterion. 5, 6
- Inappropriately reducing the dose may lead to inadequate anticoagulation and increased stroke risk. 2
Renal Function Considerations
Apixaban can be used across a wide range of renal function with standard dosing criteria applied: 7
- CrCl >30 mL/min: Apply standard dosing algorithm (5 mg twice daily unless ≥2 dose-reduction criteria met) 7
- CrCl 15-30 mL/min (severe impairment): 5 mg twice daily is still recommended unless other dose-reduction criteria are met 3
- End-stage renal disease on hemodialysis: Start with 5 mg twice daily, reduce to 2.5 mg twice daily only if age ≥80 years OR body weight ≤60 kg 7
- CrCl <15 mL/min NOT on dialysis: Contraindicated 3, 1
Administration Details
Apixaban requires twice-daily dosing due to its 9-14 hour half-life, which is essential for maintaining consistent anticoagulation levels. 3
- No loading dose or bridging anticoagulation is required when initiating therapy 7
- Can be taken with or without food 1
- If a dose is missed, take it as soon as possible on the same day; do not double the next dose 1
Switching Between Anticoagulants
From warfarin to apixaban: 1
- Discontinue warfarin and start apixaban when INR falls below 2.0
- No bridging therapy needed
From apixaban to warfarin: 1
- Discontinue apixaban and begin both parenteral anticoagulant AND warfarin at the time of the next scheduled apixaban dose
- Continue parenteral anticoagulant until INR reaches therapeutic range
From other DOACs to apixaban: 1
- Simply discontinue the other DOAC and start apixaban at the time the next dose would have been due
Monitoring Requirements
No routine coagulation monitoring is required. 3
However, assess the following periodically: 7, 3
- Renal function before starting and at least annually (more frequently if CrCl 30-50 mL/min)
- Body weight changes
- Signs of bleeding or thromboembolism
Special Clinical Scenarios
For patients requiring coronary intervention: 7
- Apixaban with clopidogrel (without aspirin) after a brief periprocedural period reduces bleeding risk while maintaining efficacy
- Apixaban monotherapy is appropriate for stable coronary disease with no recent PCI 7
Perioperative management: 1
- Discontinue at least 48 hours prior to elective surgery with moderate-to-high bleeding risk
- Discontinue at least 24 hours prior to procedures with low bleeding risk
- Bridging anticoagulation is not generally required
- Restart as soon as adequate hemostasis is established