What is the recommended dose of Eliquis (apixaban) for a patient with atrial fibrillation (AFib) and normal renal function?

Apixaban Dosing for Atrial Fibrillation

Standard Dose Recommendation

For most patients with atrial fibrillation and normal renal function, the recommended dose of apixaban is 5 mg orally twice daily. 1

Dose Reduction Algorithm

The dose should be reduced to 2.5 mg twice daily ONLY when the patient meets at least 2 of the following 3 criteria: 1, 2

• Age ≥80 years
• Body weight ≤60 kg
• Serum creatinine ≥1.5 mg/dL

This is the most critical prescribing principle: dose reduction requires TWO criteria, not just one. 2

Renal Function Considerations

Normal to Mild Renal Impairment (CrCl >50 mL/min)

• Use standard dose of 5 mg twice daily unless 2 of the 3 dose-reduction criteria are met 2, 1
• Apixaban has only 27% renal clearance, making it safer than other DOACs in renal impairment 2

Moderate Renal Impairment (CrCl 30-50 mL/min)

• Continue 5 mg twice daily unless the patient meets 2 of the 3 dose-reduction criteria 3, 2
• Moderate CKD alone does NOT trigger dose reduction 2
• Calculate creatinine clearance using the Cockcroft-Gault equation, not eGFR 3, 2

Severe Renal Impairment (CrCl 15-30 mL/min)

• Use 2.5 mg twice daily with caution 3
• Consider warfarin as an alternative if concerns about safety 2

End-Stage Renal Disease on Hemodialysis

• FDA recommends 5 mg twice daily, reduced to 2.5 mg twice daily if age ≥80 years OR weight ≤60 kg (note: only ONE criterion needed in dialysis patients) 4, 1
• This represents an exception to the usual two-criteria rule 4

Critical Prescribing Pitfalls to Avoid

Most Common Error: Inappropriate Dose Reduction

• Studies show 60.8% of patients receiving reduced-dose apixaban do not meet labeling criteria for dose reduction 5
• Clinicians frequently reduce the dose based on a single criterion (often renal function or age alone) rather than requiring two criteria 2, 5
• Do NOT reduce the dose based solely on perceived bleeding risk without meeting formal criteria 2

Specific Scenarios That Do NOT Warrant Dose Reduction Alone:

• Age 75 years with normal weight and creatinine 2
• Creatinine 1.3 mg/dL in a younger patient with normal weight 2
• Weight 65 kg in a younger patient with normal renal function 2
• CrCl 45 mL/min without meeting other criteria 2

Monitoring Requirements

Renal Function Assessment

• Calculate CrCl using Cockcroft-Gault equation before initiating therapy 3, 2
• Reassess renal function at least annually 3, 2
• Increase monitoring frequency to every 3-6 months if CrCl <60 mL/min 2
• Reassess immediately with acute illness, infections, or heart failure exacerbations 2

Drug Interactions Requiring Dose Adjustment

• Avoid or reduce dose with combined P-glycoprotein and strong CYP3A4 inhibitors (ketoconazole, ritonavir, itraconazole) 3, 2
• If using 5 mg twice daily with these inhibitors, reduce to 2.5 mg twice daily 2
• Avoid strong CYP3A4 inducers (rifampin, St. John's wort) as they decrease apixaban effectiveness 2, 1

Administration Details

Timing and Missed Doses

• Take twice daily, approximately 12 hours apart 1
• If a dose is missed, take as soon as possible on the same day and resume twice-daily schedule 1
• Do NOT double the dose to make up for a missed dose 1

Perioperative Management

• Hold for 24 hours before low bleeding risk procedures if CrCl >25 mL/min 2
• Hold for 48 hours before moderate-to-high bleeding risk procedures if CrCl >25 mL/min 2, 1
• Bridging anticoagulation is not generally required during the 24-48 hour interruption 1
• Restart as soon as adequate hemostasis is established 1

Comparative Safety Profile

Apixaban has the lowest renal clearance (27%) among DOACs, compared to dabigatran (80%) and rivaroxaban (66%), making it the preferred DOAC in patients with any degree of renal impairment 2, 6