What is the appropriate Eliquis (apixaban) dose for stroke prevention in non‑valvular atrial fibrillation, including criteria for dose reduction?

Eliquis (Apixaban) Dosing for Atrial Fibrillation

Standard Dose

The recommended dose of apixaban for stroke prevention in nonvalvular atrial fibrillation is 5 mg orally twice daily for most patients. 1

• This standard dosing demonstrated superiority over warfarin in the ARISTOTLE trial, reducing stroke or systemic embolism by 21% (HR 0.79,95% CI 0.66–0.95) and major bleeding by 31% (2.13% vs 3.09% per year). 2, 3
• No loading dose or bridging anticoagulation is required when initiating therapy. 3, 1

Dose Reduction Criteria: The "2-of-3 Rule"

Reduce apixaban to 2.5 mg twice daily ONLY when a patient meets at least TWO of the following three criteria: 1, 3

1. Age ≥80 years
2. Body weight ≤60 kg
3. Serum creatinine ≥1.5 mg/dL

Critical Pitfall to Avoid

Do NOT reduce the dose if only one criterion is present—this leads to underdosing and significantly increases thromboembolic risk without providing additional bleeding protection. 3, 4

• Real-world studies show that 60.8% of patients receiving reduced-dose apixaban do not meet the criteria for dose reduction, with age being the most common single factor inappropriately triggering dose reduction. 5
• Inappropriate dose reduction in patients meeting only one criterion may compromise stroke prevention efficacy and has been associated with higher mortality. 6, 4

Renal Function Considerations

Apixaban can be used across a broad range of renal function, including severe impairment (CrCl 15–30 mL/min), using the standard 2-of-3 dosing algorithm. 3

• For end-stage renal disease on hemodialysis: Start with 5 mg twice daily; reduce to 2.5 mg twice daily if age ≥80 years OR body weight ≤60 kg (note: only ONE criterion required in dialysis patients). 3, 7
• Contraindication: Apixaban should NOT be used in patients with CrCl <15 mL/min who are NOT on dialysis. 3, 1
• Assess renal function before initiating therapy and at least annually thereafter; monitor more frequently if CrCl is 30–50 mL/min. 3

Switching Between Anticoagulants

From Warfarin to Apixaban

• Discontinue warfarin and start apixaban when INR falls below 2.0. 1, 3
• No bridging therapy is needed. 3

From Apixaban to Warfarin

• Stop apixaban and begin both a parenteral anticoagulant AND warfarin at the time of the next scheduled apixaban dose. 1, 3
• Continue the parenteral anticoagulant until INR reaches therapeutic range. 1

From Other DOACs to Apixaban

• Simply discontinue the other DOAC and start apixaban at the time the next dose would have been due. 3

Guideline Strength

The American Heart Association/American Stroke Association gives apixaban a Class I, Level B-R recommendation for stroke prevention in nonvalvular atrial fibrillation, favoring it over warfarin. 3

• This recommendation applies regardless of atrial fibrillation pattern (paroxysmal, persistent, or permanent). 3
• DOACs including apixaban are NOT indicated in patients with moderate-to-severe mitral stenosis or mechanical heart valves. 3

Monitoring

• No routine coagulation monitoring is required. 3
• Clinical surveillance for bleeding or thrombosis is recommended. 3
• The drug's short half-life (~12 hours) means missed doses can increase thromboembolic risk. 3

Safety Considerations

• No specific antidote is currently approved for emergent reversal of apixaban, although reversal agents are under development. 3
• If a dose is missed, take it as soon as possible on the same day and resume twice-daily dosing; do NOT double the dose. 1