Can Eliquis (apixaban) be used to bridge to warfarin?

From the Guidelines

Eliquis (apixaban) should not be used to bridge to warfarin in the traditional sense, as bridging with low-molecular-weight heparin is not recommended or necessary for apixaban unless a longer period of interruption occurs. When considering the transition from apixaban to warfarin, it's essential to understand that apixaban has a shorter half-life compared to warfarin, which allows for a more predictable anticoagulant effect 1.

Key Considerations

• The half-life of apixaban is approximately 12 hours, which is shorter than that of warfarin 1.
• For patients on apixaban, the recommended approach is to withhold therapy for 24 hours (or 48 hours for patients with impaired renal function) before an invasive procedure, rather than bridging with another anticoagulant 1.
• When transitioning from apixaban to warfarin, it is recommended to continue apixaban while simultaneously starting warfarin until the INR reaches the therapeutic range 1.

Transitioning from Apixaban to Warfarin

• The dose of apixaban may need to be adjusted when warfarin is initiated, and daily INR monitoring is necessary during this transition period 1.
• Apixaban can be discontinued once the INR is consistently within the therapeutic range for at least 2 consecutive days 1.

Clinical Implications

• This approach ensures continuous anticoagulation coverage while warfarin reaches therapeutic levels, which typically takes 5-10 days 1.
• The rationale for this method is that apixaban has a predictable anticoagulant effect and shorter half-life compared to warfarin, allowing for safer overlap therapy while minimizing the risk of both bleeding and thrombotic events during the transition period 1.

From the FDA Drug Label

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 Switching from apixaban to warfarin: apixaban affects INR, so that initial INR measurements during the transition to warfarin may not be useful for determining the appropriate dose of warfarin One approach is to discontinue apixaban and begin both a parenteral anticoagulant and warfarin at the time the next dose of apixaban would have been taken, discontinuing the parenteral anticoagulant when INR reaches an acceptable range

The use of Eliquis (apixaban) to bridge to warfarin is not directly supported by the label.

• The label does discuss switching from apixaban to warfarin, but it recommends using a parenteral anticoagulant as a bridge, not apixaban itself.
• The label does not provide guidance on using apixaban as a bridge to warfarin. 2

From the Research

Apixaban as a Bridge to Warfarin

• There is limited direct evidence on the use of Eliquis (apixaban) as a bridge to warfarin, as most studies compare apixaban to warfarin or other anticoagulants in terms of efficacy and safety for the treatment of venous thromboembolism (VTE) or other conditions 3, 4, 5, 6, 7.
• However, some studies suggest that apixaban can be an effective and safe alternative to warfarin for the treatment of VTE, with lower risks of major bleeding and recurrent VTE 5, 7.
• One study found that apixaban was associated with a lower risk of major bleeding and recurrent VTE compared to rivaroxaban, another direct oral anticoagulant (DOAC) 5.
• Another study found that apixaban was non-inferior to warfarin plus subcutaneous enoxaparin bridge therapy in the treatment of acute VTE, and was associated with significantly less bleeding 7.

Clinical Practice Implications

• The available evidence suggests that apixaban can be a viable option for the treatment of VTE, with a favorable safety profile compared to warfarin and other anticoagulants 4, 5, 7.
• However, the decision to use apixaban as a bridge to warfarin should be made on a case-by-case basis, taking into account individual patient characteristics and medical history 6.
• Further studies are needed to fully evaluate the efficacy and safety of apixaban as a bridge to warfarin, particularly in specific patient populations such as those with thrombotic antiphospholipid syndrome (TAPS) 6.