What is the appropriate Eliquis (apixaban) dosing regimen for acute deep‑vein thrombosis, including loading and maintenance doses and adjustments for moderate renal impairment (creatinine clearance 30–50 mL/min), severe renal impairment (creatinine clearance <30 mL/min), and elderly patients (≥80 years) weighing ≤60 kg?

Eliquis (Apixaban) Dosing for Acute Deep Vein Thrombosis

For acute DVT, initiate apixaban 10 mg orally twice daily for 7 days, then reduce to 5 mg twice daily for a minimum of 3 months—no parenteral anticoagulation bridge is required. 1, 2, 3

Loading Phase (Days 1–7)

• Start apixaban 10 mg orally twice daily immediately upon DVT diagnosis without any heparin or enoxaparin lead-in. This direct initiation distinguishes apixaban from dabigatran and edoxaban, which require 5–10 days of parenteral therapy. 1, 2

• The AMPLIFY trial demonstrated this regimen is non-inferior to enoxaparin/warfarin for preventing recurrent VTE (2.3% vs 2.7%; RR 0.84,95% CI 0.60–1.18) while producing significantly lower major bleeding (0.6% vs 1.8%; RR 0.31,95% CI 0.17–0.55; P<0.001). 1, 3

Maintenance Phase (Day 8 Onward)

• Switch to apixaban 5 mg orally twice daily starting on day 8 and continue for at least 3 months for provoked DVT or 6 months for unprovoked DVT. 1, 2

• For unprovoked DVT, consider indefinite anticoagulation with annual reassessment of bleeding risk versus thrombotic risk. 1

Renal Impairment Adjustments

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

• Use the standard DVT treatment regimen (10 mg BID × 7 days, then 5 mg BID) without dose reduction. The age ≥80 years, weight ≤60 kg, and serum creatinine ≥1.5 mg/dL dose-reduction criteria apply only to atrial fibrillation, not to VTE treatment. 1, 2, 4

• Calculate creatinine clearance using the Cockcroft-Gault equation, as this method was used in pivotal trials and FDA labeling. 1, 4

• Apixaban has only 27% renal clearance, making it safer in renal impairment compared to dabigatran (80%) or rivaroxaban (66%). 4, 5

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

• Apixaban can be used with caution at standard initial dosing (10 mg BID × 7 days, then 5 mg BID), but consider switching to enoxaparin 1 mg/kg subcutaneously every 12 hours with anti-Xa monitoring. 1

• Meta-analysis shows bleeding risk with apixaban in moderate-to-severe renal impairment is similar to conventional anticoagulants (RR 1.01,95% CI 0.49–2.10). 5

End-Stage Renal Disease (CrCl <15 mL/min or Dialysis)

• Apixaban is contraindicated for VTE treatment in patients with CrCl <15 mL/min; use enoxaparin with anti-Xa monitoring or unfractionated heparin instead. 1

• A 2020 retrospective study in severe renal dysfunction (CrCl <25 mL/min) showed apixaban had lower combined bleeding/thrombosis events than warfarin (HR 0.47,95% CI 0.25–0.92), but this remains off-label and high-risk. 6

• A 2025 case report documented fatal intracranial hemorrhage in an ESKD patient receiving apixaban despite guideline-based dosing, highlighting the danger of even minimal renal clearance in this population. 7

Elderly Patients (≥80 Years) and Low Body Weight (≤60 kg)

• For VTE treatment, use the standard regimen (10 mg BID × 7 days, then 5 mg BID) regardless of age or weight. The dose-reduction criteria (age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL) requiring ≥2 criteria for 2.5 mg BID dosing apply only to atrial fibrillation, not DVT treatment. 1, 2, 4

• Do not confuse the VTE treatment dose with the atrial fibrillation dose—this is the most common prescribing error with apixaban. 4

Extended Therapy Beyond 6 Months

• After completing 6 months of standard-dose therapy (5 mg BID), consider reducing to apixaban 2.5 mg twice daily for extended secondary prevention to lower bleeding risk while maintaining efficacy. 1

• This reduced dose is appropriate only after the initial treatment period, never during acute or maintenance phases of the first 6 months. 1

Critical Pitfalls to Avoid

• Never use the 2.5 mg twice-daily dose for initial VTE treatment, even in elderly, low-weight patients with elevated creatinine. That dose is reserved for atrial fibrillation (when ≥2 criteria met) or extended VTE prophylaxis after 6 months. 1, 2

• Do not bridge with enoxaparin before starting apixaban for DVT. Direct initiation is the evidence-based approach. 1, 2

• Do not restart apixaban immediately after major bleeding or high-risk surgery. Wait 24–72 hours to ensure adequate hemostasis. 2

• Reassess renal function at least annually, and every 3–6 months if CrCl <60 mL/min, as declining kidney function may necessitate switching to enoxaparin. 1, 4

Monitoring Requirements

• No routine INR, anti-Xa, or D-dimer monitoring is required during apixaban therapy. 1, 2

• Obtain baseline CBC, comprehensive metabolic panel (including creatinine for CrCl calculation), and hepatic function panel (AST, ALT, bilirubin) before initiating therapy. 2

• Monitor hemoglobin/hematocrit every 2–3 days during the first 14 days if hospitalized, then every 2 weeks or as clinically indicated. 2

• Actively assess for bleeding signs (bruising, hematuria, melena, hemoptysis, neurological changes) and recurrent VTE symptoms (new leg swelling, chest pain, dyspnea). 2