What is the recommended dosing regimen for Eliquis (apixaban) in a patient with deep vein thrombosis (DVT) and presumed normal renal function?

Apixaban Dosing for Acute DVT

Start apixaban at 10 mg orally twice daily for 7 days, then reduce to 5 mg orally twice daily for at least 3 months. 1, 2

Initial Treatment Phase (Days 1-7)

• Begin with 10 mg orally twice daily for the first 7 days without requiring any initial parenteral anticoagulation (no heparin bridge needed). 1, 2
• This loading dose regimen achieves rapid anticoagulation and 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
• Take the first dose as soon as the DVT diagnosis is confirmed. 1

Maintenance Phase (After Day 7)

• Transition to 5 mg orally twice daily after completing the 7-day loading dose. 1, 2
• Continue this maintenance dose for at least 3 months for provoked DVT (DVT with a clear transient risk factor). 2
• For unprovoked DVT or DVT with persistent risk factors, strongly consider extended anticoagulation beyond 3 months. 3, 2

Extended Treatment Phase (Beyond 6 Months)

• If continuing anticoagulation beyond 6 months, reduce to 2.5 mg orally twice daily for long-term secondary prevention. 3, 1
• This reduced dose minimizes bleeding risk while maintaining efficacy for preventing recurrent DVT. 3, 2
• Extended-phase anticoagulation does not have a predefined stop date and should be reevaluated at least annually. 3

Critical Dose Adjustments and Contraindications

• Avoid apixaban if creatinine clearance <15 mL/min; use with caution if CrCl 15-25 mL/min. 2, 1
• Avoid if significant hepatic impairment (transaminases >2x upper limit of normal or total bilirubin >1.5x upper limit of normal). 2
• No dose adjustment needed for age, body weight, or mild-to-moderate renal impairment alone (unless meeting specific atrial fibrillation dose reduction criteria, which do not apply to DVT treatment). 1

Common Pitfalls to Avoid

• Do not skip or shorten the 7-day loading dose if the patient has NOT received prior parenteral anticoagulation—recent evidence suggests shortened lead-in therapy after parenteral anticoagulation increases bleeding risk (18.5% vs 5.1%). 4
• Do not double the dose if a dose is missed; simply take the next scheduled dose. 1
• Do not use the 2.5 mg twice daily dose during the initial treatment phase—this dose is only for extended prophylaxis after completing at least 6 months of treatment. 1, 3

Special Populations

Cancer-Associated DVT

• Apixaban is an acceptable alternative to LMWH in cancer patients, though LMWH (particularly dalteparin) remains preferred for the first 6 months in patients with advanced metastatic cancer. 3
• Use the same dosing regimen: 10 mg twice daily for 7 days, then 5 mg twice daily. 3

High Bleeding Risk

• If the patient has significant bleeding risk factors (P2Y12 inhibitor use, P-gp inhibitor use, elevated creatinine, advanced age), consider whether the full 7-day loading dose is appropriate or if alternative anticoagulation strategies should be employed. 4

Duration Decision Algorithm

Provoked DVT (major transient risk factor): Treat for 3 months, then stop. 3

Provoked DVT (minor transient risk factor): Treat for 3 months, generally stop (though consider patient-specific factors). 3

Unprovoked DVT or persistent risk factors: Treat for at least 3 months, then strongly consider extended anticoagulation with reduced-dose apixaban 2.5 mg twice daily. 3, 2