From the Guidelines
For a male patient with new onset atrial fibrillation and a CHA₂DS₂-VASc score of 3, I strongly recommend starting anticoagulation with Eliquis (apixaban) at a dose of 5 mg twice daily, as this has been shown to be effective in preventing stroke and systemic embolism while minimizing bleeding risks, as supported by the 2021 ACC/AHA clinical performance and quality measures for adults with atrial fibrillation or atrial flutter 1.
This standard dosing is appropriate for most patients, but should be reduced to 2.5 mg twice daily if the patient has at least two of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL, as indicated in the 2018 Circulation study on antithrombotic therapy in patients with atrial fibrillation treated with oral anticoagulation undergoing percutaneous coronary intervention 1.
Before initiating therapy, it is essential to:
- Assess renal function
- Evaluate liver function
- Check for potential drug interactions
- Conduct baseline complete blood count and coagulation studies
Eliquis should be taken consistently at approximately 12-hour intervals with or without food. Patients should be counseled about:
- Bleeding risks
- The importance of not missing doses
- Informing all healthcare providers about this medication before procedures
Anticoagulation for a CHA₂DS₂-VASc score of 3 is strongly recommended as it indicates a substantial annual stroke risk, and the benefits of stroke prevention typically outweigh bleeding risks in this scenario, as emphasized in the 2021 ACC/AHA guidelines 1.
Key considerations for the management of atrial fibrillation include:
- Selection of anticoagulant therapy based on the risk of thromboembolism
- Individualization of anticoagulant therapy based on shared decision-making after discussion of the absolute risks and relative risks of stroke and bleeding, as well as the patient’s values and preferences
- Reevaluation of the need for and choice of anticoagulant therapy at periodic intervals to reassess stroke and bleeding risks, as recommended in the 2021 ACC/AHA guidelines 1.
From the FDA Drug Label
1.1 Reduction of Risk of Stroke and Systemic Embolism in Nonvalvular Atrial Fibrillation Apixaban tablets are indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. 2.1 Recommended Dose Reduction of Risk of Stroke and Systemic Embolism in Patients with Nonvalvular Atrial Fibrillation The recommended dose of apixaban tablets for most patients is 5 mg taken orally twice daily.
For a male patient with new onset atrial fibrillation and a CHADSVASC score of 3, the recommended dose of apixaban (Eliquis) is 5 mg taken orally twice daily 2.
- Key considerations:
- The patient's renal function and body weight should be assessed to determine if a dose reduction to 2.5 mg twice daily is necessary.
- The patient should be closely monitored for signs and symptoms of bleeding and thrombotic events.
- Dose adjustment:
- If the patient has at least two of the following characteristics: age ≥ 80 years, body weight ≤ 60 kg, or serum creatinine ≥ 1.5 mg/dL, the dose should be reduced to 2.5 mg twice daily.
From the Research
Eligibility for Eliquis (Apixaban) in New Onset AFib with CHADSVASC Score of 3
- For a male patient with a CHADSVASC score of 3, the risk of stroke is significant, and anticoagulation therapy is recommended 3.
- The CHADSVASC score is a clinical stroke risk score that helps identify patients at high risk of stroke, and a score of 3 indicates a moderate to high risk of stroke.
Dosing of Eliquis (Apixaban)
- The standard dose of apixaban for stroke prevention in patients with non-valvular atrial fibrillation is 5 mg twice daily 4, 5.
- However, for patients with severe renal impairment (creatinine clearance < 25 mL/min), a reduced dose of 2.5 mg twice daily may be considered 4, 6.
- It is essential to note that the dosing of apixaban may vary depending on the patient's renal function and other clinical factors, and the decision to start apixaban and the dosing should be individualized based on the patient's specific needs and risk factors.
Safety and Efficacy of Apixaban in Patients with Renal Impairment
- Studies have shown that apixaban is effective and safe in patients with moderate to severe renal impairment, including those with end-stage renal disease (ESRD) 5, 6.
- Apixaban has been associated with a lower risk of bleeding and thromboembolic events compared to warfarin in patients with ESRD 6.
- However, it is crucial to monitor patients with renal impairment closely for signs of bleeding and adjust the dose as needed.
Considerations for Starting Eliquis (Apixaban) in New Onset AFib
- For a male patient with new onset AFib and a CHADSVASC score of 3, starting apixaban may be a reasonable option, considering the patient's renal function and other clinical factors 7, 3.
- The decision to start apixaban should be based on a thorough evaluation of the patient's risk factors, including the risk of stroke, bleeding, and other clinical considerations.