What is the recommended dosage of Eliquis (apixaban) for the treatment of Deep Vein Thrombosis (DVT) in adult patients with and without severe renal impairment?

Eliquis (Apixaban) Dosing for DVT Treatment

For DVT treatment, start Eliquis at 10 mg orally twice daily for the first 7 days, then reduce to 5 mg twice daily for at least 3 months, with no need for initial parenteral anticoagulation. 1

Initial Treatment Phase (Days 1-7)

• Loading dose: 10 mg orally twice daily for 7 days to achieve rapid anticoagulation 2, 3, 1
• This regimen eliminates the need for initial heparin or enoxaparin bridging therapy 2, 3
• The AMPLIFY trial validated this approach, demonstrating non-inferiority to conventional enoxaparin/warfarin therapy with significantly lower major bleeding rates (0.6% vs 1.8%) 4, 2, 5

Maintenance Phase (After Day 7)

• Continue with 5 mg orally twice daily after completing the 7-day loading dose 2, 3, 1
• Treat for at least 3 months for provoked DVT 2, 3
• For unprovoked DVT or patients with ongoing risk factors, consider extending treatment beyond 3 months 2

Extended Secondary Prevention (After 6 Months)

• Reduce to 2.5 mg orally twice daily for long-term prevention of recurrent DVT after completing at least 6 months of initial therapy 2, 6, 1
• This lower dose minimizes bleeding risk while maintaining efficacy for preventing recurrent events 2, 6
• The AMPLIFY-EXTEND trial demonstrated that 2.5 mg twice daily reduced recurrent VTE without increasing major bleeding compared to placebo 4, 6

Critical Contraindications and Dose Adjustments

Severe Renal Impairment

• Avoid apixaban if creatinine clearance <15 mL/min 4, 2, 1
• Use caution if CrCl <25 mL/min, as these patients were excluded from clinical trials 4, 2, 6

Hepatic Impairment

• Avoid apixaban if transaminases >2× upper limit of normal or total bilirubin >1.5× upper limit of normal 4, 2, 6
• Patients with significant hepatic impairment were excluded from clinical trials 4

Important Clinical Caveats

Missed Dose Management

• If a dose is missed, take it as soon as possible on the same day and resume twice-daily dosing 1
• Never double the dose to make up for a missed dose 1

Surgical Interruption

• Discontinue at least 48 hours prior to elective surgery with moderate-to-high bleeding risk 1
• Discontinue at least 24 hours prior to procedures with low bleeding risk 1
• Bridging anticoagulation during the 24-48 hour interruption is not generally required 1

Parenteral Anticoagulation Overlap

• If parenteral anticoagulation (heparin/enoxaparin) was already initiated before starting apixaban, recent evidence suggests shortened lead-in therapy may increase bleeding risk 7
• The full 7-day loading dose of 10 mg twice daily should be completed even after parenteral therapy, particularly in patients with bleeding risk factors including P2Y12 inhibitor use, P-gp inhibitor use, elevated creatinine, or advanced age 7

Cancer-Associated DVT

• Apixaban is a viable option for cancer-associated DVT, demonstrating non-inferiority to dalteparin without increased major bleeding (3.8% vs 4.0%) 8
• Use the same dosing regimen: 10 mg twice daily for 7 days, then 5 mg twice daily 8