What is the recommended dosing regimen for Eliquis (apixaban) in an adult patient with pulmonary embolism (PE) and no significant renal impairment?

Apixaban Dosing for Pulmonary Embolism

For an adult patient with pulmonary embolism and no significant renal impairment, start apixaban 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)

• Administer apixaban 10 mg orally twice daily for the first 7 days to ensure rapid therapeutic anticoagulation during the acute phase 1, 2
• No parenteral anticoagulation (such as enoxaparin or heparin) is required before starting apixaban, which is a key advantage over dabigatran and allows for immediate initiation upon diagnosis 1, 3
• Treatment can begin immediately once PE is confirmed, provided no contraindications exist 1
• Do not continue the 10 mg twice daily dose beyond 7 days, as this increases bleeding risk without additional benefit 1

Maintenance Phase (Day 8 Onward)

• After completing 7 days of 10 mg twice daily, reduce to 5 mg orally twice daily 1, 2
• Continue this maintenance dose for at least 3 months minimum 1
• For unprovoked PE or patients with ongoing risk factors, extended anticoagulation beyond 3 months should be considered 1

Extended Secondary Prevention (After 6 Months)

• After completing at least 6 months of initial therapy, either 5 mg twice daily or 2.5 mg twice daily can be used for extended secondary prevention 1, 2
• The choice between these doses depends on balancing thrombosis risk versus bleeding risk in individual patients 1

Renal Function Considerations

• Use apixaban with caution in severe renal impairment (creatinine clearance <30 mL/min) 1
• For patients with creatinine clearance ≥30 mL/min, no dose adjustment is needed for the standard PE treatment regimen 1
• Patients with age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL may require special consideration, but these criteria apply primarily to atrial fibrillation dosing, not acute PE treatment 1

Drug Interactions Requiring Dose Adjustment

• When apixaban 5 mg or 10 mg twice daily is coadministered with combined P-glycoprotein and strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir), reduce the apixaban dose by 50% 2
• In patients already taking 2.5 mg twice daily, avoid coadministration with these inhibitors 2

Safety Profile and Bleeding Risk

• Apixaban demonstrates superior bleeding safety compared to conventional enoxaparin/warfarin therapy, with major bleeding rates of only 0.6% versus 1.8% 1, 3
• The composite of major bleeding plus clinically relevant non-major bleeding occurs in 4.3% with apixaban versus 9.7% with conventional therapy 1, 3
• Apixaban should be preferred in patients at elevated bleeding risk due to its 69% relative reduction in major bleeding 3

Critical Pitfalls to Avoid

• Never administer loading doses of parenteral anticoagulants when initiating apixaban, as this significantly increases bleeding risk without improving efficacy 1
• Recent evidence suggests that patients who receive parenteral anticoagulation followed by shortened apixaban lead-in therapy may experience increased bleeding events, particularly those with bleeding risk factors 4
• Do not extend the 10 mg twice daily dose beyond 7 days, as this increases bleeding without additional therapeutic benefit 1
• If apixaban is discontinued for reasons other than pathological bleeding or completion of therapy, consider coverage with another anticoagulant to prevent thrombotic events 2

Administration for Patients Unable to Swallow

• Apixaban tablets may be crushed and suspended in water, 5% dextrose in water, or apple juice, or mixed with applesauce and administered orally 2
• Alternatively, tablets may be crushed and suspended in 60 mL of water or D5W and delivered through a nasogastric tube 2

Monitoring Requirements

• No routine coagulation monitoring (such as INR) is required, as apixaban has a predictable anticoagulant effect 1
• Evaluate for medication adherence and bleeding complications at follow-up visits 1

Temporary Interruption for Procedures

• Discontinue apixaban at least 48 hours prior to elective surgery or procedures with moderate-to-high bleeding risk 2
• For procedures with low bleeding risk, discontinue at least 24 hours prior 2
• Bridging anticoagulation during the 24-48 hour interruption is not generally required 2
• Restart apixaban as soon as adequate hemostasis is established post-procedure 2