What is the recommended dose of Eliquis (apixaban) for a patient with pulmonary embolism (PE) and normal renal function?

Eliquis Dosing for Pulmonary Embolism

For acute pulmonary embolism treatment in patients with normal renal function, start Eliquis (apixaban) at 10 mg orally twice daily for the first 7 days, then reduce to 5 mg twice daily for at least 3 months. 1

Initial Treatment Phase (Days 1-7)

• Apixaban 10 mg orally twice daily for 7 days is the FDA-approved initial dose for acute PE treatment 1
• No parenteral anticoagulation (heparin or enoxaparin) is required before starting apixaban, unlike dabigatran or edoxaban 2, 3
• Treatment should be initiated immediately upon PE diagnosis 3
• This higher initial dose ensures rapid therapeutic anticoagulation during the acute phase 3

Maintenance Phase (Day 8 onwards)

• After 7 days, reduce to 5 mg orally twice daily 1, 2
• Continue this dose for a minimum of 3 months 2
• Do not continue the 10 mg twice daily dose beyond 7 days, as this increases bleeding risk 3

Duration of Therapy

• Minimum 3 months for all PE patients 2
• For unprovoked PE or ongoing risk factors, extended anticoagulation beyond 3 months may be necessary 2
• After at least 6 months of treatment, consider reducing to 2.5 mg twice daily for extended secondary prevention 1

Renal Function Considerations

• Apixaban can be used in patients with creatinine clearance ≥30 mL/min without dose adjustment 2
• Use with caution in severe renal impairment (creatinine clearance <30 mL/min) 2, 3
• For patients with creatinine clearance <30 mL/min, consider alternative anticoagulation such as unfractionated heparin 2

Efficacy and Safety Profile

• Apixaban demonstrated non-inferiority to conventional enoxaparin/warfarin therapy for preventing recurrent VTE 2
• Major bleeding rate significantly lower with apixaban (0.6%) versus conventional therapy (1.8%) 2, 3
• Combined major and clinically relevant non-major bleeding substantially reduced: 4.3% with apixaban versus 9.7% with conventional therapy 2, 3
• Recent data confirms apixaban is the most commonly prescribed anticoagulant for PE in U.S. emergency departments (40% of cases) 4

Critical Pitfalls to Avoid

• Never administer loading doses of parenteral anticoagulants when initiating apixaban, as this unnecessarily increases bleeding risk 3
• Do not double the dose if a dose is missed; take the next scheduled dose 1
• Do not continue 10 mg twice daily beyond the first 7 days 3, 1
• Discontinue at least 48 hours before elective surgery with moderate-to-high bleeding risk 1
• Reduce dose by 50% when coadministered with combined P-gp and strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir) 1

Administration Options

• For patients unable to swallow tablets, apixaban may be crushed and suspended in water, D5W, apple juice, or mixed with applesauce 1
• Can be administered via nasogastric tube when crushed and suspended in 60 mL of water or D5W 1

Advantages Over Traditional Therapy

• No routine coagulation monitoring required (unlike warfarin) 3
• More predictable anticoagulant effect compared to vitamin K antagonists 3
• Single-drug regimen without need for heparin bridge 2
• Superior safety profile with significantly less bleeding 2, 5