From the Guidelines
For patients with pulmonary embolism, initiation of anticoagulation with heparin is recommended without delay, while diagnostic workup is in progress, and Eliquis (apixaban) can be started after initial heparin therapy, usually within 24-48 hours if the patient is stable. When oral anticoagulation is started, a NOAC (such as apixaban) is recommended in preference to a VKA 1. The choice between heparin and Eliquis depends on the patient's clinical probability of PE, renal function, and bleeding risk.
- Heparin (either unfractionated heparin or low molecular weight heparin) is preferred initially in hemodynamically unstable patients with massive PE, as it can be reversed if bleeding complications occur or if thrombolysis becomes necessary.
- Eliquis is typically started at a dose of 10mg twice daily for 7 days, followed by 5mg twice daily for at least 3 months.
- For patients with uncomplicated PE who are candidates for early discharge, some protocols allow starting Eliquis directly without heparin bridging, but this should be done with caution and careful assessment of the patient's risk factors 1.
- It is essential to assess renal function, bleeding risk, and patient stability before choosing either medication, with dose adjustments needed for patients with renal impairment.
- NOACs, including Eliquis, are not recommended in patients with severe renal impairment, during pregnancy and lactation, and in patients with antiphospholipid antibody syndrome 1.
From the FDA Drug Label
- 5 Acute PE in Hemodynamically Unstable Patients or Patients who Require Thrombolysis or Pulmonary Embolectomy Initiation of apixaban tablets are not recommended as an alternative to unfractionated heparin for the initial treatment of patients with PE who present with hemodynamic instability or who may receive thrombolysis or pulmonary embolectomy.
INDICATIONS AND USAGE HEPARIN SODIUM INJECTION is an anticoagulant indicated for • Prophylaxis and treatment of venous thrombosis and pulmonary embolism
Pulmonary Embolism Treatment
- Eliquis (Apixaban): Not recommended for initial treatment in patients with hemodynamic instability or those who may require thrombolysis or pulmonary embolectomy 2.
- Heparin: Indicated for prophylaxis and treatment of pulmonary embolism 3. In patients with pulmonary embolism, heparin can be started immediately, whereas apixaban is not recommended as an initial treatment in certain cases.
From the Research
Pulmonary Embolism Treatment
- The treatment of pulmonary embolism typically involves anticoagulant therapy to reduce the risk of recurrence and mortality 4, 5, 6, 7, 8.
- Low-molecular-weight heparin (LMWH) is often used as the initial treatment for pulmonary embolism, as it has been shown to be at least as effective as unfractionated heparin (UFH) with a similar risk of bleeding 4, 5.
- Direct oral anticoagulants (DOACs) such as apixaban, edoxaban, rivaroxaban, and dabigatran are also used for the treatment of pulmonary embolism and have been shown to be noninferior to heparin and warfarin with a lower rate of bleeding 7, 8.
When to Start Eliquis (Apixaban)
- Apixaban can be started immediately for the treatment of pulmonary embolism, without the need for initial parenteral anticoagulant therapy 8.
- The fixed-dose regimen of oral apixaban alone is as effective as conventional treatment regimens and is associated with a clinically relevant reduction of major bleeding 8.
When to Use Heparin
- Unfractionated heparin is generally recommended for patients with renal failure or those who require close monitoring of their anticoagulation therapy 4, 6.
- Low-molecular-weight heparin can be used as an alternative to unfractionated heparin in patients without renal failure 4, 5.
- Heparin is often used in combination with a vitamin K antagonist such as warfarin for the initial treatment of pulmonary embolism, but DOACs are becoming increasingly popular due to their simplicity and safety profile 6, 7, 8.