What is the recommended treatment with Eliquis (apixaban) for a patient with a history of non-valvular atrial fibrillation, deep vein thrombosis, or pulmonary embolism, considering their kidney function and other medical conditions?

Apixaban (Eliquis) Treatment Recommendations

Standard Dosing for Nonvalvular Atrial Fibrillation

For most patients with nonvalvular atrial fibrillation, the recommended dose is 5 mg orally twice daily, with dose reduction to 2.5 mg twice daily only when patients meet at least 2 of 3 specific criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL. 1

Dose Reduction Criteria

• Reduce to 2.5 mg twice daily when at least 2 of the following are present: 1
  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL
• Do not reduce dose if only one criterion is met 2
• This dosing algorithm was validated in the ARISTOTLE trial, which demonstrated 21% reduction in stroke/systemic embolism (HR 0.79,95% CI 0.66-0.95) and 31% reduction in major bleeding compared to warfarin 2, 3

Renal Impairment Considerations

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

• Standard dosing algorithm applies—use 5 mg twice daily unless dose reduction criteria are met 2
• Apixaban has only 27% renal clearance, making it safer than dabigatran (80% renal) or rivaroxaban (66% renal) in renal impairment 3
• Assess renal function before initiation and at least annually, with more frequent monitoring if CrCl 30-50 mL/min 2

End-Stage Renal Disease on Hemodialysis

• Start with 5 mg twice daily 2, 1
• Reduce to 2.5 mg twice daily only if age ≥80 years OR body weight ≤60 kg (note: different criteria than non-dialysis patients—only one criterion needed, not two) 2, 3
• Observational data from 25,523 dialysis patients showed apixaban had similar stroke prevention to warfarin (HR 0.88,95% CI 0.69-1.12) but significantly lower major bleeding risk (HR 0.72,95% CI 0.59-0.87) 4

Contraindications

• Do not use apixaban in patients with CrCl <15 mL/min who are not on dialysis 2, 1

Deep Vein Thrombosis and Pulmonary Embolism

Acute Treatment Phase

• Initial dose: 10 mg orally twice daily for the first 7 days 1
• Maintenance dose: 5 mg orally twice daily after day 7 1

Prevention of Recurrent DVT/PE

• After completing at least 6 months of treatment: 2.5 mg orally twice daily 1

Post-Surgical Prophylaxis

• Hip or knee replacement: 2.5 mg orally twice daily starting 12-24 hours after surgery 1
• Duration: 35 days for hip replacement, 12 days for knee replacement 1

Switching Between Anticoagulants

From Warfarin to Apixaban

• Discontinue warfarin and start apixaban when INR falls below 2.0 1
• No bridging therapy required 2, 1

From Apixaban to Warfarin

• Discontinue apixaban and begin both parenteral anticoagulant and warfarin at the time of next scheduled apixaban dose 1
• Continue parenteral anticoagulant until INR reaches therapeutic range 1
• Initial INR measurements during transition are not useful due to apixaban's effect on INR 1

From Other DOACs to Apixaban

• Simply discontinue the other DOAC and start apixaban at the time the next dose would have been due 1

Special Clinical Situations

Patients with Prior Stroke

• Use the same standard dosing algorithm—apixaban's benefit is independent of prior stroke history 2
• The ARISTOTLE trial demonstrated consistent benefits across subgroups including patients with prior stroke/TIA 3

Patients Requiring Coronary Intervention

• After brief periprocedural period, use apixaban with clopidogrel without aspirin to reduce bleeding risk while maintaining efficacy 2
• For stable coronary disease without recent PCI, apixaban monotherapy is appropriate—adding antiplatelet therapy increases bleeding without clear benefit 2

Cardioversion

• Apixaban is equivalent to warfarin for cardioversion with at least 3 weeks of therapeutic anticoagulation pre-procedure 4
• TEE-guided approach with abbreviated anticoagulation is acceptable—apixaban's rapid onset allows initiation closer to procedure than warfarin 4

Perioperative Management

Elective Surgery or Invasive Procedures

• Moderate to high bleeding risk: Discontinue at least 48 hours prior 1
• Low bleeding risk: Discontinue at least 24 hours prior 1
• Bridging anticoagulation during the 24-48 hour interruption is not generally required 1
• Restart as soon as adequate hemostasis is established 1

Drug Interactions

Strong CYP3A4 and P-glycoprotein Inhibitors

• Avoid concomitant use with combined inhibitors (ketoconazole, ritonavir, itraconazole) in patients receiving 5 mg twice daily 3
• If necessary, reduce to 2.5 mg twice daily 3

Critical Safety Warnings

Premature Discontinuation Risk

• Premature discontinuation increases risk of thrombotic events 1
• If discontinuing for reasons other than pathological bleeding or completion of therapy, provide coverage with another anticoagulant 1

Neuraxial Anesthesia Risk

• Epidural or spinal hematomas may occur with neuraxial anesthesia or spinal puncture, potentially causing permanent paralysis 1
• Risk factors include indwelling epidural catheters, concomitant NSAIDs or antiplatelet agents, history of spinal procedures, and spinal deformity 1
• Monitor frequently for neurological impairment; urgent treatment is necessary if compromise occurs 1

Monitoring Requirements

• No routine coagulation monitoring required 2
• Assess renal function before initiation and at least annually 2
• More frequent renal monitoring if CrCl 30-50 mL/min or risk factors for deterioration 2
• Monitor for signs of bleeding or thromboembolism 2

Missed Dose Management

• Take missed dose as soon as possible on the same day 1
• Resume twice-daily administration 1
• Do not double the dose to make up for missed dose 1
• Apixaban has a 12-hour half-life, making adherence critical 2