What is the recommended dosing regimen for a patient with non-valvular atrial fibrillation or at risk for recurrent deep vein thrombosis and pulmonary embolism starting on Eliquis (apixaban) therapy, considering their renal function and potential need for alternative anticoagulants?

Eliquis (Apixaban) Starter Pack Dosing

For Venous Thromboembolism (DVT/PE)

For acute DVT or PE treatment, start with apixaban 10 mg orally twice daily for exactly 7 days, then transition to 5 mg twice daily for maintenance therapy. 1

• This initiation dose must be completed first before transitioning to the usual treatment dose 1
• No parenteral lead-in therapy (heparin/LMWH) is required with apixaban, unlike dabigatran or edoxaban which require at least 5 days of parenteral anticoagulation 1
• After 6 months of initial treatment, either 5 mg twice daily or 2.5 mg twice daily can be considered for extended secondary prevention 1

For Non-Valvular Atrial Fibrillation

For atrial fibrillation, start with 5 mg orally twice daily immediately—no loading dose or starter pack is needed. 2

• Reduce to 2.5 mg twice daily ONLY if the patient meets at least 2 of the following 3 criteria: age ≥80 years, body weight ≤60 kg, OR serum creatinine ≥1.5 mg/dL 2, 3
• No bridging anticoagulation is required when initiating therapy 2

Renal Function Considerations for Atrial Fibrillation

• Standard 5 mg twice daily dosing applies for CrCl >30 mL/min (or even down to CrCl 25-30 mL/min based on recent evidence) 2, 4
• For end-stage renal disease on hemodialysis: start with 5 mg twice daily, reducing to 2.5 mg twice daily only if age ≥80 years OR body weight ≤60 kg 2
• Apixaban is contraindicated in patients with CrCl <15 mL/min who are NOT on dialysis 2, 3

Critical Practical Points

Switching From Warfarin to Apixaban

• Discontinue warfarin and start apixaban when INR falls below 2.0—no bridging therapy needed 2

Switching 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

Renal Monitoring Requirements

• Assess renal function before starting and at least annually thereafter 2, 3
• Monitor more frequently (2-3 times per year) if CrCl 30-50 mL/min or other risk factors for deterioration exist 1, 2

Common Pitfalls to Avoid

• Do NOT use a "starter pack" dosing for atrial fibrillation—this is only for VTE treatment 1, 2
• Do NOT overdose-reduce: The 2.5 mg twice daily dose for atrial fibrillation requires meeting at least 2 of 3 dose-reduction criteria, not just one 3
• Do NOT use dual DOAC therapy: If a patient has both VTE and atrial fibrillation, use a single anticoagulant at the VTE treatment dose to cover both indications 5
• Do NOT assume all DOACs have the same initiation regimen: Rivaroxaban uses 15 mg twice daily for 21 days for VTE (not 7 days like apixaban), and dabigatran/edoxaban require parenteral lead-in 1, 6