Eliquis (apixaban) dosage guide: getting the dose right

The most common reason for prescribing Eliquis in the UK is to prevent stroke in patients with non-valvular atrial fibrillation.

Standard dose:

• 5 mg twice daily (morning and evening, approximately 12 hours apart)

Reduced dose (2.5 mg twice daily) if at least two of the following apply:

• Age 80 years or over
• Body weight 60 kg or under
• Serum creatinine 133 micromol/L or above (approximately eGFR 25 to 30)

This dose reduction criterion is specific to atrial fibrillation and does not apply to the same thresholds in other indications.

The BNF is very clear that the dose should only be reduced when at least two of these three criteria are met simultaneously.

Important prescribing notes:

• Eliquis should not be used in patients with severe hepatic impairment or those with a creatinine clearance below 15 ml/min
• Patients with moderate hepatic impairment (Child-Pugh B) should be prescribed with caution
• NICE technology appraisal TA275 recommends apixaban as an option for preventing stroke in non-valvular AF, in line with CHA2DS2-VASc scoring

Patients should be counselled that twice-daily dosing is essential for maintaining a stable anticoagulant effect throughout the day.

Eliquis is licensed for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE). The dosing schedule differs from the AF dose.

Treatment phase:

• 10 mg twice daily for the first 7 days, then
• 5 mg twice daily for the remainder of the treatment course

Duration of treatment:

• Typically 3 to 6 months for a first provoked DVT or PE
• Longer (sometimes indefinite) treatment may be recommended for unprovoked events or recurrent VTE, based on an individual risk-benefit assessment

The initial higher dose (10 mg twice daily) provides rapid anticoagulation during the acute phase when the clot burden is highest.

This eliminates the need for initial treatment with injected heparin, which was previously required with warfarin.

Key advantages of Eliquis for DVT/PE:

• No need for bridging with low-molecular-weight heparin
• Fixed dosing without the need for INR monitoring
• Rapid onset of action
• Lower risk of major bleeding compared to warfarin in the AMPLIFY trial

NICE (TA341) recommends apixaban as an option for treating and preventing recurrent DVT and PE in adults.

Eliquis is also licensed for the prevention of venous thromboembolism (VTE) following elective hip or knee replacement surgery.

Dosage for surgical VTE prevention:

• 2.5 mg twice daily, starting 12 to 24 hours after surgery

Duration:

• Hip replacement: 32 to 38 days
• Knee replacement: 10 to 14 days

The first dose should be given 12 to 24 hours after surgery, once haemostasis has been achieved. If the first dose cannot be given on the day of surgery, it should be started the following day.

Practical considerations:

• No dose reduction is needed for elderly patients or those with mild to moderate renal impairment
• The medicine should be avoided in patients with severe renal impairment (creatinine clearance below 15 ml/min)
• Hospital pharmacists will usually set up the initial prescription and provide patient counselling before discharge
• After discharge, the GP will be informed of the treatment duration and expected stop date

This indication reflects NICE guidance on VTE prevention in surgical patients, which recommends pharmacological thromboprophylaxis for all adults undergoing major orthopaedic surgery.

For patients who have completed at least 6 months of treatment for DVT or PE and require ongoing anticoagulation to prevent recurrence, the BNF recommends a reduced dose.

Extended prevention of recurrent VTE:

• 2.5 mg twice daily, following completion of at least 6 months of standard treatment (5 mg twice daily)

The decision to continue long-term anticoagulation is made on an individual basis, weighing the risk of recurrent VTE against the risk of bleeding. Factors that favour extended treatment include:

• Unprovoked DVT or PE (no identifiable trigger)
• Recurrent VTE
• Active cancer
• Ongoing risk factors such as immobility or thrombophilia

The reduced 2.

5 mg twice daily dose for extended prevention has been shown in the AMPLIFY-EXT trial to reduce the risk of recurrent VTE by approximately 67% compared to placebo, with a bleeding rate similar to placebo.

Your doctor will review the need for continued anticoagulation at regular intervals, typically every 6 to 12 months.

Because Eliquis is taken twice daily, maintaining a consistent schedule is important. Here is what to do if you miss a dose.

NHS guidance on missed doses:

• If you remember within 6 hours of the scheduled time, take the missed dose immediately and then take the next dose at the usual time
• If more than 6 hours have passed, skip the missed dose and take the next one at the normal time
• Never take a double dose to make up for a missed one

Why consistent dosing matters:

Apixaban has a half-life of approximately 12 hours, which is why it is dosed twice daily.

Missing a dose means your blood will be less effectively anticoagulated for a period, increasing your clot risk. Taking a double dose increases your bleeding risk.

Tips for remembering:

• Use a daily pill organiser with AM and PM compartments
• Set two alarms on your phone, 12 hours apart
• Link each dose to a daily routine (for example, breakfast and evening meal)
• Use the NHS app or a medication reminder app

If you find you are frequently missing doses, discuss this with your pharmacist or GP. Adherence is one of the most important factors in ensuring Eliquis works effectively.

Unlike warfarin, Eliquis does not require routine dose adjustments based on blood tests. However, there are specific situations where the dose must be modified.

Renal impairment:

• Mild to moderate (creatinine clearance 25 to 80 ml/min): no dose adjustment needed, but the dose reduction criteria for AF still apply
• Severe (creatinine clearance 15 to 24 ml/min): use with caution; the 2.5 mg twice daily dose is recommended for AF
• End-stage renal disease (creatinine clearance below 15 ml/min): not recommended

Hepatic impairment:

• Mild (Child-Pugh A): no dose adjustment
• Moderate (Child-Pugh B): use with caution, no specific dose adjustment in the BNF but careful monitoring is advised
• Severe (Child-Pugh C): contraindicated

Drug interactions requiring dose reduction:

• Strong dual CYP3A4 and P-glycoprotein inhibitors (such as ketoconazole, itraconazole, ritonavir): reduce dose from 5 mg to 2.5 mg twice daily. If the patient is already on 2.5 mg twice daily, avoid the combination

Body weight:

• Low body weight alone (without other criteria) does not mandate a dose reduction in the AF indication; at least two of the three criteria must be met

For a discussion of side effects and how to recognise bleeding complications, see our dedicated page.