Synopsis
Select, prescribe and review anticoagulation using the indication, treatment phase, kidney function and the competing consequences of thrombosis and bleeding.
- Write the indication and treatment phase before selecting a dose: atrial-fibrillation prevention, acute venous thrombosis treatment and extended recurrence prevention use different schedules.
- For non-valvular atrial fibrillation, apixaban is usually 5 mg orally twice daily long term; use 2.5 mg twice daily when at least two of age 80 years or over, weight 60 kg or less and serum creatinine 133 micromol/L or over apply.
- Apixaban for acute DVT or PE is 10 mg orally twice daily for 7 days, then 5 mg twice daily; assess treatment duration at 3 months. The 2.5 mg twice-daily recurrence-prevention regimen follows at least 6 months of treatment.
Key red flags
Haemodynamic instability, suspected intracranial bleeding, haematemesis or a rapidly expanding haematoma in an anticoagulated person requires emergency assessment and an immediate reversal discussion.
A new painful swollen limb, hypoxia or focal neurological deficit despite treatment requires investigation; do not assume that an anticoagulant excludes thrombosis.
Investigation priorities
Establish baseline blood counts and detect occult blood loss.
Management branches
A stable adult has an agreed indication for stroke-prevention anticoagulation.
- Confirm the rhythm diagnosis and risk assessment, discuss expected benefit and bleeding concerns, then exclude circumstances needing a different strategy, including a mechanical valve or pregnancy. Agree who will prescribe and monitor after initiation.
- Check weight, full blood count, liver function and creatinine clearance. Apply the product-specific criteria to the selected agent and indication; do not combine thresholds remembered from several different DOACs into an invented dose rule.
Key medicines
Apixaban for non-valvular atrial fibrillation5 mg orally twice daily long term; reduce to 2.5 mg twice daily for at least two of age ≥80 years, weight ≤60 kg and serum creatinine ≥133 micromol/L, or for CrCl 15–29 mL/min.UK SmPC regimen, distinct from VTE dosing. Not recommended with CrCl below 15 mL/min or dialysis; avoid hepatic coagulopathy, assess major interactions and pregnancy, and reassess during acute illness.
Apixaban for DVT or pulmonary embolism10 mg orally twice daily for 7 days, then 5 mg twice daily; review duration at 3 months. For continuing recurrence prevention after at least 6 months, 2.5 mg orally twice daily.National duration review and product dose schedule answer different questions. Use caution with CrCl 15–29 mL/min; not recommended below 15 mL/min. Do not import AF age/weight dose-reduction criteria into acute VTE treatment.