What is the recommended dose of apixaban for patients with non-valvular atrial fibrillation or venous thromboembolism?

Apixaban Dosing for Nonvalvular Atrial Fibrillation and Venous Thromboembolism

For nonvalvular atrial fibrillation, prescribe apixaban 5 mg orally twice daily as the standard dose, reducing to 2.5 mg twice daily ONLY when patients meet at least TWO of three criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1

Atrial Fibrillation Dosing Algorithm

Standard Dosing

• The FDA-approved standard dose is 5 mg orally twice daily for most patients with nonvalvular atrial fibrillation 1
• This dosing demonstrated a 21% reduction in stroke or systemic embolism compared to warfarin (HR 0.79,95% CI 0.66-0.95) and a 31% reduction in major bleeding in the ARISTOTLE trial 2, 3

Dose Reduction Criteria (Must Meet ≥2 of 3)

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

Critical pitfall: Reducing the dose based on only ONE criterion is off-label and may lead to inadequate anticoagulation with increased stroke risk 4, 5. Studies show that 60.8% of patients receiving reduced-dose apixaban did not meet proper criteria for dose reduction 6, and inappropriately underdosed patients may face increased thromboembolic risk 4.

Renal Function Considerations

• For CrCl >30 mL/min: Apply standard dosing algorithm (5 mg twice daily unless ≥2 dose-reduction criteria met) 3
• For CrCl 15-30 mL/min: Use 5 mg twice daily unless ≥2 dose-reduction criteria are met 2, 3
• For end-stage renal disease on hemodialysis: Start 5 mg twice daily, reduce to 2.5 mg twice daily only if age ≥80 years OR body weight ≤60 kg 2, 3
• For CrCl <15 mL/min NOT on dialysis: Apixaban is contraindicated 2, 1

Venous Thromboembolism Dosing

Acute DVT/PE Treatment

• Initial 7 days: 10 mg orally twice daily 1
• After 7 days: 5 mg orally twice daily for completion of treatment course 1

Extended Treatment (Recurrence Prevention)

• After completing at least 6 months of anticoagulation for DVT or PE, use 2.5 mg orally twice daily for extended prophylaxis 1

Post-Surgical VTE Prophylaxis

• Following hip or knee replacement: 2.5 mg orally twice daily starting 12-24 hours after surgery 1
• Duration: 35 days for hip replacement, 12 days for knee replacement 1

Important caveat: The evidence for apixaban in cancer-associated VTE is limited, with only 2.7% of patients in the AMPLIFY trial having active cancer 7. Consider alternative agents with stronger evidence in this population 7.

Monitoring Requirements

• Assess renal function before initiation and at least annually thereafter 3
• Monitor renal function more frequently if CrCl 30-50 mL/min or other risk factors for deterioration exist 2, 3
• Evaluate body weight periodically, particularly in patients near the 60 kg threshold 3
• No routine coagulation monitoring is required 2
• Assess clinically for signs of bleeding or thromboembolism 2

Switching Between Anticoagulants

From Warfarin to Apixaban

• Discontinue warfarin and start apixaban when INR falls below 2.0 1
• No bridging therapy is needed 2

From Apixaban to Warfarin

• Discontinue apixaban and begin both parenteral anticoagulant AND warfarin at the time of the next scheduled apixaban dose 1
• Continue parenteral anticoagulant until INR reaches therapeutic range 1

From Other DOACs to Apixaban

• Simply discontinue the other DOAC and start apixaban at the time the next dose of the previous DOAC would have been due 2, 1

Special Populations

Patients with Prior Stroke/TIA

• Use the same dosing algorithm—apixaban benefit is independent of prior stroke history 2, 3

Patients Requiring Antiplatelet Therapy

• After coronary intervention, use apixaban with clopidogrel (NOT aspirin) after a brief periprocedural period to reduce bleeding risk while maintaining efficacy 2, 3
• For stable coronary disease without recent PCI, apixaban monotherapy is appropriate—adding antiplatelet therapy increases bleeding without clear benefit 2