Apixaban Dosing Recommendations
For most adults with atrial fibrillation, the standard dose is apixaban 5 mg orally twice daily, with dose reduction to 2.5 mg twice daily ONLY when at least TWO of the following criteria are met: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1, 2
Standard Dosing for Atrial Fibrillation
- The recommended dose is 5 mg orally twice daily for stroke prevention in nonvalvular atrial fibrillation 1, 2
- 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 1, 3, 4
- No loading dose or bridging anticoagulation is required when initiating therapy 3
Dose Reduction Criteria: The "Two Out of Three" Rule
Reduce to 2.5 mg twice daily ONLY when the patient has at least TWO of these characteristics: 1, 2
- Age ≥80 years
- Body weight ≤60 kg
- Serum creatinine ≥1.5 mg/dL
Critical Pitfall to Avoid
- Patients with only ONE dose-reduction criterion should receive the standard 5 mg twice daily dose 5
- In the ARISTOTLE trial, 3,966 patients with only one criterion received 5 mg twice daily and showed consistent benefit compared to warfarin for both efficacy (HR 0.94,95% CI 0.66-1.32) and bleeding (HR 0.68,95% CI 0.53-0.87) 5
- Inappropriately reducing the dose in patients with fewer than two criteria may lead to inadequate anticoagulation and increased stroke risk 6, 7
Renal Function Considerations
For patients with CrCl >30 mL/min: 1
- Apply the standard dosing algorithm (5 mg twice daily unless ≥2 dose-reduction criteria met)
For patients with CrCl 15-30 mL/min: 1, 3
- Start with 5 mg twice daily
- Reduce to 2.5 mg twice daily only if age ≥80 years OR body weight ≤60 kg (note: only ONE additional criterion needed in severe renal impairment)
For patients with end-stage renal disease on hemodialysis: 1, 3, 2
- Start with 5 mg twice daily
- Reduce to 2.5 mg twice daily only if age ≥80 years OR body weight ≤60 kg
For patients with CrCl <15 mL/min NOT on dialysis: 3
- Apixaban is contraindicated
Monitoring Renal Function
- Assess renal function before initiating therapy and at least annually thereafter 3, 4
- More frequent monitoring is warranted if CrCl 30-50 mL/min or other risk factors for deterioration are present 3
Dosing for Deep Vein Thrombosis and Pulmonary Embolism
Treatment of acute DVT/PE: 2
- 10 mg orally twice daily for the first 7 days
- Then 5 mg orally twice daily for continued treatment
Prevention of recurrent DVT/PE: 2
- 2.5 mg orally twice daily after at least 6 months of initial treatment
Prophylaxis after hip or knee replacement: 2
- 2.5 mg orally twice daily starting 12-24 hours post-surgery
- Duration: 35 days for hip replacement, 12 days for knee replacement
Special Populations and Situations
Patients with prior stroke or TIA: 3, 4
- Use the same dosing algorithm; apixaban benefit is independent of prior stroke history
Patients requiring concurrent antiplatelet therapy (post-PCI): 1, 3
- Apixaban 5 mg twice daily (or 2.5 mg twice daily if ≥2 dose-reduction criteria met) 1
- Clopidogrel is the preferred P2Y12 inhibitor when combined with apixaban 3
- Avoid triple therapy with aspirin when possible to reduce bleeding risk 1
Patients with stable coronary disease (no recent PCI): 3
- Apixaban monotherapy is appropriate; adding antiplatelet therapy increases bleeding without clear benefit
Switching Between Anticoagulants
From warfarin to apixaban: 2
- Discontinue warfarin and start apixaban when INR falls below 2.0
- No bridging therapy needed
From apixaban to warfarin: 2
- 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: 2
- Simply discontinue the other DOAC and start apixaban at the time the next dose of the previous DOAC would have been due
Perioperative Management
For low bleeding risk procedures: 1
- Hold apixaban for 1 full day before procedure (if CrCl >25 mL/min)
For high bleeding risk procedures: 1
- Hold apixaban for 2 full days before procedure (if CrCl >25 mL/min)
Resumption after surgery: 2
- Restart apixaban as soon as adequate hemostasis has been established
- Bridging anticoagulation during the 24-48 hours after stopping apixaban is not generally required 2
Monitoring After Initiation
- No routine coagulation monitoring is required 3
- Assess for signs of bleeding or thromboembolism clinically 3, 4
- Evaluate body weight periodically, particularly in patients near the 60 kg threshold 4
- Renal function assessment as outlined above 3, 4