What apixaban (Eliquis) dose is appropriate for an octogenarian with prior pulmonary embolism, a pacemaker, chronic kidney disease and severe anemia (hemoglobin 6.9 g/dL) pending transfusion?

Apixaban Dosing in an Octogenarian with Multiple Comorbidities and Severe Anemia

Hold apixaban immediately and do not restart until hemoglobin is stable above 10 g/dL and the source of anemia is identified and treated. The combination of severe anemia (Hgb 6.9 g/dL) requiring transfusion with any anticoagulant creates unacceptable bleeding risk that outweighs thrombotic concerns in this clinical scenario.

Immediate Management: Anticoagulation Hold

• Stop apixaban now until hemoglobin stabilizes above 10 g/dL and the cause of severe anemia is fully investigated and addressed 1, 2.

• Severe anemia (Hgb 6.9 g/dL) represents active or recent major bleeding until proven otherwise; continuing anticoagulation in this setting dramatically increases mortality risk 2.

• The patient's history of PE 2-3 years ago does not constitute an acute thrombotic indication requiring immediate anticoagulation during active bleeding or severe anemia 1.

• A pacemaker alone does not create an anticoagulation indication—the relevant question is whether the patient has atrial fibrillation requiring stroke prevention 3, 1.

When to Resume: Dosing Algorithm After Stabilization

Step 1: Calculate Creatinine Clearance

• Use the Cockcroft-Gault equation with actual body weight to determine renal function, not eGFR 3, 4.

• The patient's CKD stage will determine whether renal impairment alone mandates dose reduction 3, 4.

Step 2: Apply the FDA "2-of-3" Dose-Reduction Criteria

For CrCl >30 mL/min:

• Count how many of these three criteria the patient meets 1, 3:

  1. Age ≥80 years ✓ (patient is in late 80s)
  2. Body weight ≤60 kg (unknown from question)
  3. Serum creatinine ≥1.5 mg/dL (depends on CKD severity)

• If ≥2 criteria are met: Use apixaban 2.5 mg twice daily 1, 3.

• If 0-1 criteria are met: Use apixaban 5 mg twice daily 1, 3.

For CrCl 15-29 mL/min (CKD Stage 4):

• Use apixaban 2.5 mg twice daily for all patients—severe renal impairment alone mandates dose reduction regardless of age or weight 4, 3.

For CrCl <15 mL/min or dialysis (CKD Stage 5):

• FDA permits apixaban 5 mg twice daily, reduced to 2.5 mg twice daily if age ≥80 years OR weight ≤60 kg (only one criterion required for dialysis patients) 5, 4.

• However, warfarin with TTR >65-70% is preferred first-line for dialysis-dependent patients 4, 5.

• If apixaban is chosen for dialysis, the patient's age ≥80 years alone would trigger dose reduction to 2.5 mg twice daily 5.

Critical Pitfalls to Avoid

• Do not reduce apixaban dose based on perceived bleeding risk, frailty, or a single criterion when CrCl >30 mL/min—this is the most common prescribing error and leads to underdosing with increased stroke risk 3.

• Do not use eGFR for dosing decisions—the Cockcroft-Gault creatinine clearance was used in all pivotal trials and FDA labeling 3, 4.

• Do not restart apixaban until the source of severe anemia is identified—occult GI bleeding, hematuria, or other bleeding sources must be excluded before resuming any anticoagulant 2.

• Apixaban has only 27% renal clearance, making it safer than dabigatran (80%) or rivaroxaban (66%) in CKD, but severe anemia overrides this advantage 3, 4.

Special Considerations for This Patient

Anemia Management Takes Priority

• The case report of a 73-year-old with CKD who developed pleural, pericardial, and intracranial hemorrhages on apixaban—despite guideline-based dosing—illustrates that even "appropriate" dosing can cause catastrophic bleeding in advanced CKD 2.

• Rare hemorrhagic complications (pleural, pericardial, intracranial) can occur in severe CKD even with reduced-dose apixaban 2.

Pacemaker Consideration

• A pacemaker alone does not require anticoagulation 3.

• If the pacemaker was placed for atrial fibrillation with bradycardia, then stroke prevention is indicated—but this must be balanced against bleeding risk 3.

Remote PE History

• A PE 2-3 years ago that has been treated does not require indefinite anticoagulation unless there is recurrent VTE or ongoing thrombotic risk 6.

• If the patient completed 6-12 months of anticoagulation after the PE, extended therapy with apixaban 2.5 mg twice daily may reduce recurrence risk, but this is elective and should be deferred until anemia resolves 6, 1.

Monitoring After Restart

• Reassess renal function every 3-6 months given CKD and age >80 years 3, 4.

• Monitor hemoglobin regularly—apixaban increases major bleeding risk even in stable CKD 2, 7.

• No routine INR monitoring is needed for apixaban 3.