What is the treatment for bridging off Eliquis (apixaban) in patients with pulmonary embolism (PE)?

From the Guidelines

When bridging off Eliquis for treating pulmonary embolism (PE), it is crucial to initiate anticoagulation with a low molecular weight heparin (LMWH) or unfractionated heparin (UFH) without delay, as recommended by the 2019 ESC guidelines 1. The choice of anticoagulant for bridging depends on the patient's risk factors and clinical status.

• For patients with high-risk PE, anticoagulation with UFH, including a weight-adjusted bolus injection, is recommended 1.
• In general, LMWH such as enoxaparin can be used for bridging, administered at 1 mg/kg twice daily subcutaneously, starting 12 hours after the last Eliquis dose.
• The bridging therapy usually continues for 5-7 days until adequate anticoagulation is achieved with a different medication.
• If transitioning to warfarin, continue the LMWH until the INR reaches the therapeutic range of 2-3 for at least 24 hours.
• It is essential to note that systemic thrombolytic therapy is recommended for high-risk PE 1, and surgical pulmonary embolectomy or percutaneous catheter-directed treatment may be considered in specific cases.
• The bridging approach should always be supervised by a healthcare provider who can adjust the specific timing and dosing based on individual risk factors, kidney function, and bleeding risk.

From the FDA Drug Label

If anticoagulation with apixaban is discontinued for a reason other than pathological bleeding or completion of a course of therapy, consider coverage with another anticoagulant [see Dosage and Administration (2.4), Warnings and Precautions (5.1), and Clinical Studies (14. 1)]. Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding [see Warnings and Precautions (5. 2)] . Bridging anticoagulation during the 24 to 48 hours after stopping apixaban tablets and prior to the intervention is not generally required Apixaban tablets should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established.

When bridging off Eliquis (apixaban) for the treatment of Pulmonary Embolism (PE), the drug label recommends:

• Discontinuing apixaban at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding.
• Bridging anticoagulation is not generally required during the 24 to 48 hours after stopping apixaban tablets and prior to the intervention.
• Apixaban should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established.
• Consider coverage with another anticoagulant if apixaban is discontinued for a reason other than pathological bleeding or completion of a course of therapy 2.

From the Research

Treating Pulmonary Embolism (PE) with Eliquis (Apixaban)

• Eliquis (Apixaban) is a direct oral anticoagulant (DOAC) that is approved for the acute treatment of deep-vein thrombosis (DVT) and pulmonary embolism (PE) as well as for the reduction in the risk of recurrent DVT and PE following initial therapy 3.
• The current 2019 guidelines of the European Society of Cardiology (ESC) recommend that all eligible patients should be treated with a non-vitamin K antagonist oral anticoagulant (NOAC), such as Apixaban, in preference to a vitamin K antagonist (VKA) 4.
• Apixaban is an effective alternative to treatment with low molecular weight heparins (LMWH) in patients with active cancer 4.

Bridging Therapy with Low Molecular Weight Heparin (LMWH)

• LMWH is at least as effective as unfractionated heparin (UFH) in the treatment of PE, with a similar risk of bleeding 5.
• LMWH offers more predictable pharmacokinetics and anticoagulant effects compared to UFH 5.
• The use of LMWH is recommended over UFH in patients with submassive PE, according to current guidelines from both the American College of Chest Physicians and the joint American College of Physicians/American Academy of Family Physicians 5.

Duration of Anticoagulation Therapy

• All patients with PE require therapeutic anticoagulation for at least three months 4.
• The decision on the duration of anticoagulation should consider both the individual risk of PE recurrence and the individual risk of bleeding 4.
• Extended oral anticoagulation of indefinite duration should be considered for all patients with intermediate risk of recurrence, given the favorable safety profile of NOACs 4.