What is the recommended dose of Eliquis (apixaban) for a patient with deep vein thrombosis (DVT) and normal renal function?

Eliquis Dosing for DVT

For acute DVT treatment in patients with normal renal function, start Eliquis (apixaban) at 10 mg orally twice daily for 7 days, then reduce to 5 mg twice daily for continued treatment. 1

Initial Treatment Phase (Days 1-7)

• Loading dose: 10 mg orally twice daily for exactly 7 days 2, 3, 4, 1
• No initial parenteral anticoagulation (heparin or enoxaparin) is required before starting apixaban, which distinguishes it from dabigatran and edoxaban 4, 1
• This loading regimen was validated in the AMPLIFY trial, demonstrating non-inferiority to conventional enoxaparin/warfarin therapy with significantly lower major bleeding rates (0.6% vs 1.8%) 2, 4

Maintenance Phase (After Day 7)

• Standard dose: 5 mg orally twice daily 2, 3, 4, 1
• Continue this dose for a minimum of 3 months for provoked DVT 4
• For unprovoked DVT or persistent risk factors, consider extended therapy beyond 3 months 2, 4

Extended Treatment Phase (After 6 Months)

• Reduced dose option: 2.5 mg orally twice daily 2, 1
• This reduced dose is specifically for secondary prevention after completing at least 6 months of full-dose therapy 2, 5
• The CHEST guidelines suggest using reduced-dose apixaban over full-dose for extended therapy, balancing efficacy with bleeding risk 2
• Critical pitfall: Do not use 2.5 mg twice daily before completing 6 months of full-dose therapy—this is only validated for extended secondary prevention 5

Renal Function Considerations

• No dose adjustment needed for CrCl ≥15 mL/min 3
• Apixaban has favorable renal profile with only 27% renal elimination 3
• Avoid in severe renal impairment (CrCl <15 mL/min) and use caution with CrCl <25 mL/min 4, 5

Duration of Treatment Algorithm

Provoked DVT (major transient risk factor):

• Treat for 3 months, then stop anticoagulation 2, 4
• Do not offer extended-phase therapy 2

Unprovoked DVT or persistent risk factors:

• Treat for minimum 3 months with 5 mg twice daily 4
• Offer extended-phase anticoagulation indefinitely 2
• After 6 months, consider reducing to 2.5 mg twice daily 2, 1
• Reassess at least annually 2, 5

Important Clinical Caveats

Drug interactions requiring dose reduction:

• When coadministered with combined P-gp and strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir), reduce the 5 mg or 10 mg twice daily dose by 50% 1
• Avoid coadministration entirely in patients already taking 2.5 mg twice daily 1

Missed dose management:

• Take the missed dose as soon as possible on the same day 1
• Resume twice-daily schedule 1
• Never double the dose 1

Surgical interruption:

• Discontinue at least 48 hours before procedures with moderate-to-high bleeding risk 1
• Discontinue at least 24 hours before low-risk procedures 1
• Bridging anticoagulation is not generally required 1

Administration alternatives:

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

Evidence Quality Note

The recommendation for 10 mg twice daily for 7 days followed by 5 mg twice daily is supported by FDA labeling 1, American College of Cardiology guidelines 2, 3, and the landmark AMPLIFY trial 2. Recent research suggests that shortening the 7-day lead-in period after parenteral anticoagulation may increase bleeding risk, particularly in patients with bleeding risk factors 6, reinforcing the importance of completing the full 7-day loading regimen as prescribed.