What is the comparison between Apixaban (Eliquis) and Enoxaparin (Lovenox) for atrial fibrillation (AFib)?

From the Guidelines

Eliquis (apixaban) is generally preferred over Lovenox (enoxaparin) for atrial fibrillation (AFib) management. Eliquis is an oral medication taken twice daily (typically 5mg twice daily, or 2.5mg twice daily for patients with certain risk factors like age ≥80, weight ≤60kg, or serum creatinine ≥1.5mg/dL), while Lovenox requires subcutaneous injections once or twice daily. For long-term AFib management, Eliquis provides more convenient administration and has been specifically approved for stroke prevention in AFib, demonstrating effectiveness in reducing stroke risk while causing fewer bleeding complications compared to warfarin 1. Lovenox is not FDA-approved for long-term AFib management and is typically used for shorter durations or in specific situations like perioperative bridging therapy.

Key Points to Consider

• Eliquis works by directly inhibiting factor Xa in the coagulation cascade, while Lovenox is a low molecular weight heparin that works by enhancing antithrombin activity.
• Both medications require dose adjustments for kidney function, and neither should be abruptly discontinued due to increased stroke risk.
• The ARISTOTLE trial demonstrated that apixaban was significantly better than warfarin, with fewer overall strokes, systemic emboli, and major bleeding events 1.
• Always consult with your healthcare provider before making any medication changes, as individual factors may influence which anticoagulant is most appropriate for your specific situation.

Important Considerations

• Patients with severe and end-stage CKD (serum creatinine >2.5 mg/dL or CrCl <25 mL/min) were excluded from the ARISTOTLE and AVERROES trials 1.
• Apixaban was superior to aspirin for secondary prevention of stroke or systemic embolism, with a similar rate of major bleeding 1.
• The risk of stroke was similar for patients assigned to rivaroxaban and warfarin, but apixaban had a lower risk of major bleeding compared to warfarin 1.

From the Research

Comparison of Eliquis and Lovenox for AFib

• Eliquis (apixaban) is a direct factor Xa inhibitor that has been shown to be effective in reducing the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (AF) 2.
• Lovenox (enoxaparin) is a low molecular weight heparin that is often used as a bridge therapy in patients with AF who are at high risk of stroke or systemic embolism.
• A systematic review of apixaban in patients with AF found that it has a predictable pharmacokinetic profile and does not require routine anticoagulation monitoring 3.
• Another study found that apixaban is associated with a lower risk of stroke or systemic embolism and major bleeding compared to warfarin in patients with nonvalvular AF 4.
• However, there is limited direct comparison between Eliquis and Lovenox for AFib, and the choice of anticoagulant often depends on individual patient factors and clinical guidelines.

Efficacy and Safety of Apixaban

• Apixaban has been shown to be effective in reducing the risk of stroke or systemic embolism in patients with nonvalvular AF, with a lower risk of major bleeding compared to warfarin 2, 4.
• A systematic review and meta-analysis found that apixaban is associated with a lower risk of thromboembolic events, bleeding, and mortality compared to warfarin in patients with nonvalvular AF 5.
• However, the study also found that the higher risk profiles of patients in observational studies versus randomized controlled trials, and higher rates of both bleeding and mortality not attributable to thromboembolism in patients treated with apixaban 2.5 versus 5 mg twice daily, suggest that differences in patient characteristics are additional important contributors to the higher than expected thromboembolic event rates in clinical practice 5.

Dosage and Patient Characteristics

• Apixaban is available in two doses: 5 mg twice daily and 2.5 mg twice daily 4.
• Patients prescribed 2.5 mg twice daily apixaban were older, had clinically more severe comorbidities, and were more likely to have a history of stroke and bleeding compared with 5 mg twice daily apixaban patients 4.
• Both apixaban doses were associated with a lower risk of stroke or systemic embolism and major bleeding compared to warfarin in the distinct population for which it is being prescribed in United States clinical practice 4.