What is the dosing protocol for transitioning from Heparin to Apixaban (Eliquis) for Deep Vein Thrombosis (DVT) treatment?

From the Guidelines

To transition from heparin to Eliquis (apixaban) for deep vein thrombosis (DVT) treatment, discontinue heparin and start Eliquis 10 mg twice daily for the first 7 days, followed by 5 mg twice daily for at least 3 months, as recommended by the most recent guidelines 1. The transition should be immediate with no overlap needed between medications. For patients already on intravenous unfractionated heparin, start Eliquis at the time of heparin discontinuation. For those on low molecular weight heparin (LMWH), administer the first dose of Eliquis 0-2 hours before the next scheduled LMWH dose would have been given. This clean transition works because Eliquis has a rapid onset of action (reaching peak plasma levels within 3-4 hours) and provides immediate anticoagulation effect, as supported by the American Society of Hematology 2020 guidelines for management of venous thromboembolism 1. Some key considerations for this transition include:

• Ensuring the patient has normal renal function, as dose adjustments may be needed for severe renal impairment, as noted in the 2020 ACC expert consensus decision pathway for anticoagulant and antiplatelet therapy 1.
• Patients should take Eliquis with or without food at approximately the same times each day.
• Counseling patients about bleeding risks and the importance of not missing doses is crucial, as highlighted in the venous thromboembolism in cancer patients: ESMO clinical practice guideline 1. The most recent and highest quality study, the ESMO clinical practice guideline 1, supports the use of apixaban for DVT treatment, with a reduced risk of recurrent VTE and similar risk of major bleeding compared to dalteparin.

From the FDA Drug Label

2.4 Converting from or to apixaban Switching from anticoagulants other than warfarin (oral or parenteral) to apixaban: Discontinue the anticoagulant other than warfarin and begin taking apixaban at the usual time of the next dose of the anticoagulant other than warfarin.

The dosing for transitioning from heparin to Eliquis (apixaban) for DVT treatment is to discontinue heparin and begin taking apixaban at the usual time of the next dose of heparin. The recommended dose of apixaban for DVT treatment is 10 mg taken orally twice daily for the first 7 days of therapy, then 5 mg taken orally twice daily after 7 days 2.

From the Research

Transitioning from Heparin to Eliquis (Apixaban) for DVT Treatment

• The traditional treatment of venous thromboembolism (VTE) with heparin and warfarin has numerous limitations, and new oral anticoagulants like apixaban represent a promising alternative 3.
• Apixaban is an oral factor Xa inhibitor with a rapid onset of action and predictable pharmacokinetics, allowing for a fixed-dose regimen 3.
• Studies have shown that apixaban is as effective as conventional treatment regimens and is associated with a clinically relevant reduction of major bleeding 3, 4.
• The fixed-dose regimen of oral apixaban alone can be used for the treatment of VTE, eliminating the need for initial parenteral anticoagulant therapy and laboratory monitoring 3.

Dosing and Efficacy of Apixaban

• Apixaban has been shown to be effective in the treatment of deep-vein thrombosis (DVT) and pulmonary embolism (PE) at a dose of 5 mg twice daily 4, 5.
• Extended anticoagulation with apixaban at a treatment dose (5 mg twice daily) or thromboprophylactic dose (2.5 mg twice daily) reduces the risk of recurrent venous thromboembolism without increasing the rate of major bleeding 3.
• Biomarker levels of coagulation activity, such as D-dimer and prothrombin fragment 1+2, decrease over 12 weeks of treatment with apixaban, consistent with the low rate of venous thromboembolism observed 6.

Safety and Comparison to Other Treatments

• Apixaban has been shown to be safe and effective in patients with acute DVT, with a low incidence of major and clinically relevant non-major bleeding 7.
• The safety profile of apixaban is comparable to that of low-molecular-weight heparin (LMWH) followed by a vitamin K antagonist (VKA) 7.
• Apixaban offers several advantages over historical therapy for the treatment and secondary prevention of VTE, including a fixed-dose regimen and reduced need for laboratory monitoring 4.