What is the recommended apixaban dosing regimen for an adult with acute deep‑vein thrombosis and no contraindications, including dose‑reduction criteria?

Apixaban Dosing for Acute Deep Vein Thrombosis

For an adult with acute DVT and no contraindications, 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 10 mg orally twice daily for the first 7 days as the loading dose regimen to achieve rapid anticoagulation 1, 2
• No initial parenteral anticoagulation (heparin or LMWH) is required before starting apixaban, which distinguishes it from dabigatran and edoxaban 1, 2
• This loading dose was validated in the AMPLIFY trial with 5,395 patients, demonstrating non-inferiority to enoxaparin/warfarin with significantly superior safety (major bleeding 0.6% vs 1.8%, P<0.001) 1

Maintenance Phase (After Day 7)

• Transition to 5 mg orally twice daily after completing the initial 7-day loading period 1, 2
• Continue this maintenance dose for a minimum of 3 months for provoked DVT 2
• For unprovoked DVT or ongoing risk factors, consider extending treatment beyond 3 months with periodic reassessment 2

Extended Treatment Phase (After 6 Months)

• For patients requiring anticoagulation beyond 6 months, reduce to 2.5 mg orally twice daily for secondary prevention 1, 2
• This reduced dose minimizes bleeding risk while maintaining efficacy for preventing recurrent DVT 2
• Extended-phase anticoagulation should be reevaluated at least annually 3

Dose Reduction Criteria

No dose reduction is required during the initial or maintenance treatment phases for DVT 1, 2

The dose reduction criteria for apixaban (age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL) apply only to stroke prevention in atrial fibrillation, not to DVT treatment 1, 2

Critical Contraindications and Cautions

• Avoid apixaban in severe renal impairment (CrCl <15 mL/min) 1, 2
• Use caution with CrCl <25 mL/min, as patients below this threshold were excluded from clinical trials 1
• Avoid in significant hepatic impairment (transaminases >2× upper limit of normal or total bilirubin >1.5× upper limit of normal) 1
• Discontinue at least 48 hours prior to elective surgery with moderate-to-high bleeding risk, or 24 hours for low-risk procedures 2

Key Advantages Over Traditional Therapy

• Fixed-dose regimen eliminates the need for routine laboratory monitoring (no INR checks required) 4
• Single-drug approach without initial heparin bridging simplifies treatment 1, 4
• Superior safety profile with 69% relative risk reduction in major bleeding compared to enoxaparin/warfarin (RR 0.31,95% CI 0.17-0.55) 1

Common Pitfalls to Avoid

• Do not apply atrial fibrillation dose-reduction criteria to DVT treatment—the 2.5 mg twice daily dose is only for extended secondary prevention after 6 months, not for acute treatment 1, 2
• Do not start with heparin bridging—apixaban's loading dose provides adequate immediate anticoagulation 1, 2
• Do not double the dose if a dose is missed—take the missed dose as soon as possible on the same day and resume the regular twice-daily schedule 2

Special Population: Cancer-Associated DVT

• While earlier guidelines expressed caution due to limited cancer patient enrollment (only 2.7% in AMPLIFY), apixaban is now recognized as a viable option for cancer-associated DVT 1
• More recent evidence supports apixaban as noninferior to dalteparin for cancer-associated VTE 3, 5