What is the initial dose of Eliquis (apixaban) for a patient with a new occlusion noted on Doppler (duplex ultrasonography)?

Initial Apixaban Dosing for New Venous Thromboembolism

For a patient with a new venous thrombosis (DVT or PE) detected on Doppler ultrasound, start apixaban at 10 mg orally twice daily for the first 7 days, then reduce to 5 mg twice daily for continued treatment. 1, 2

Treatment Dosing Regimen

• Days 1-7: Apixaban 10 mg orally twice daily 1, 3, 2
• Day 8 onward: Apixaban 5 mg orally twice daily 1, 3, 2

This is the standard therapeutic regimen for acute VTE treatment and is not a loading dose—it is the required initial treatment dose. 3 Failure to use this higher initial dose may compromise efficacy. 3

Key Advantages of Apixaban for VTE

• No bridging required: Unlike dabigatran or edoxaban, apixaban can be started immediately as monotherapy without parenteral anticoagulation (heparin/LMWH). 3, 2
• Immediate therapeutic effect: Begin apixaban at the time of diagnosis; do not use parenteral anticoagulation as a "bridge" as this increases bleeding risk without benefit. 3

Renal Function Considerations

• CrCl >30 mL/min: Use standard dosing (10 mg BID × 7 days, then 5 mg BID) with no adjustment needed. 1, 4
• CrCl 15-30 mL/min: No FDA-approved recommendation for VTE treatment; consider alternative anticoagulation. 1, 2
• CrCl <15 mL/min or dialysis: Apixaban is not recommended for VTE treatment in this population. 1

Common Pitfalls to Avoid

• Do not confuse VTE dosing with atrial fibrillation dosing: The AF dose is 5 mg BID (or 2.5 mg BID with dose-reduction criteria), which is insufficient for acute VTE treatment. 1, 5
• Do not use 2.5 mg BID initially: This dose is only for VTE secondary prevention after completing at least 6 months of standard therapy, not for acute treatment. 1
• Do not bridge with heparin/LMWH: This is unnecessary with apixaban and increases bleeding risk. 3, 2
• Do not apply AF dose-reduction criteria (age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL) to VTE treatment dosing: These criteria only apply to atrial fibrillation, not VTE treatment. 5, 4

Duration of Treatment

• Provoked VTE (surgery, trauma, temporary risk factor): Minimum 3 months of treatment 1
• Unprovoked VTE or ongoing risk factors: Consider extended therapy; after 6 months, may reduce to 2.5 mg BID for secondary prevention. 1
• Cancer-associated VTE: Consider LMWH (dalteparin or enoxaparin) as first-line per NCCN guidelines, though apixaban is an acceptable alternative. 1

Special Circumstances

• If surgery is planned within 3 months of VTE diagnosis: Defer elective procedures until completing the initial treatment course when possible. 1
• If patient develops renal dysfunction during treatment: Reassess renal function regularly; if CrCl drops below 30 mL/min, transition to warfarin may be necessary. 1