What is the recommended treatment for a patient with pulmonary embolism, including anticoagulation with heparin and Eliquis (apixaban)?

From the Guidelines

The recommended duration of anticoagulation with heparin before transitioning to Eliquis (apixaban) for a patient with pulmonary embolism is at least 5 days, as this allows for adequate overlap with oral anticoagulation and minimizes the risk of bleeding complications. When initiating anticoagulation for pulmonary embolism, parenteral heparin, such as unfractionated heparin (UFH) or low molecular weight heparin (LMWH), is typically used initially, with UFH administered as an IV bolus of 80 units/kg followed by a continuous infusion of 18 units/kg/hour, adjusted to maintain an aPTT of 1.5-2.5 times normal 1. For patients transitioning to Eliquis (apixaban), the standard regimen is 10 mg twice daily for 7 days, followed by 5 mg twice daily for at least 3 months, as recommended by recent guidelines 1. The choice of anticoagulant and duration of treatment depend on various factors, including the severity of the pulmonary embolism, the presence of comorbidities, and the risk of bleeding complications. Key considerations in the management of pulmonary embolism include:

• Initiation of anticoagulation without delay in patients with high or intermediate clinical probability of PE 1
• Preference for non-vitamin K antagonist oral anticoagulants (NOACs) such as apixaban over vitamin K antagonists (VKAs) for most patients 1
• Overlapping parenteral anticoagulation with oral anticoagulation until an INR of 2.5 (range 2.0-3.0) is reached for patients treated with VKAs 1
• Monitoring for bleeding complications, the most serious side effect of anticoagulation. In patients with hemodynamically unstable pulmonary embolism, thrombolytic therapy may be considered, and in cases where anticoagulation is contraindicated, an inferior vena cava filter might be placed 1.

From the FDA Drug Label

2.4 Converting from or to apixaban Switching from warfarin to apixaban: Warfarin should be discontinued and apixaban started when the international normalized ratio (INR) is below 2. 0. There is no information about transitioning from heparin gtt to apixaban.

The FDA drug label does not answer the question.

From the Research

Anticoagulation Treatment for Pulmonary Embolism

The treatment for pulmonary embolism typically involves anticoagulation with heparin, followed by transition to a direct oral anticoagulant such as Eliquis (apixaban) 2, 3.

Duration of Heparin Treatment

The duration of heparin treatment before transitioning to Eliquis is typically 7-10 days, overlapped with warfarin sodium during the last 4-5 days 2. However, a recent study suggests that 4-5 days of initial heparin therapy may be effective and safe, but this approach requires further evaluation 2.

Transition to Eliquis

Direct oral anticoagulants such as apixaban are noninferior to heparin combined with a vitamin K antagonist for treating pulmonary embolism, with a lower rate of bleeding 3. The current guidelines recommend the use of non-vitamin K antagonist oral anticoagulants (NOACs) in preference to vitamin K antagonists (VKAs) for eligible patients 4.

Key Considerations

• The decision on the duration of anticoagulation should consider both the individual risk of pulmonary embolism recurrence and the individual risk of bleeding 4.
• Patients with a strong transient risk factor have a low risk of recurrence, and anticoagulation can be discontinued after three months 4.
• Patients with strong persistent risk factors, such as active cancer, have a high risk of recurrence and should receive anticoagulant treatment of indefinite duration 4.
• The use of low-molecular-weight heparin (LMWH) is at least as effective as unfractionated heparin (UFH) in the treatment of pulmonary embolism, with a similar risk of bleeding 5.

Monitoring and Adjustment

• The majority of patients with acute pulmonary embolism spend most of their first 48 hours outside of the therapeutic range of anticoagulation when treated with guideline standard dosing of unfractionated heparin 6.
• Over half of the patients fail to achieve any therapeutic partial thromboplastin time (PTT) level within 24 hours of heparin initiation, and no patient had all therapeutic aPTTs 6.

Some key points to consider when treating a patient with pulmonary embolism include:

• The use of heparin as an initial treatment, followed by transition to a direct oral anticoagulant such as Eliquis
• The duration of heparin treatment, typically 7-10 days
• The importance of monitoring and adjusting anticoagulation therapy to ensure therapeutic levels are achieved
• The consideration of individual risk factors for recurrence and bleeding when determining the duration of anticoagulation
• The preference for non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists (VKAs) for eligible patients 2, 3, 4.