How do I switch a patient with bilateral pulmonary embolism (PE) from a heparin (unfractionated heparin) infusion to Eliquis (apixaban)?

From the Guidelines

To switch a patient with bilateral pulmonary embolism from a heparin infusion to Eliquis (apixaban), stop the heparin infusion and immediately start apixaban at a dose of 10 mg twice daily for the first 7 days, followed by 5 mg twice daily thereafter. This recommendation is based on the most recent guidelines for the management of acute pulmonary embolism, which suggest the use of non-vitamin K antagonist oral anticoagulants (NOACs) like apixaban over traditional anticoagulants due to their favorable risk-benefit profile 1. The decision to switch to apixaban is supported by its rapid onset of action, which allows for the discontinuation of heparin at the time of the first apixaban dose, eliminating the need for an overlap period between the two medications. Key considerations in the management of these patients include the assessment of bleeding risk and the identification of modifiable risk factors, as well as regular monitoring for signs of bleeding or recurrent thrombosis during the transition to apixaban 1. For patients with specific conditions such as renal impairment, dose adjustments may be necessary, such as considering a reduced dose of 2.5 mg twice daily after the initial 7-day treatment period for those with a creatinine clearance of 15-29 mL/min. The advantages of apixaban include fixed oral dosing without the need for routine monitoring, no dietary restrictions, and fewer drug interactions compared to warfarin, making it a preferred choice for long-term anticoagulation in patients with pulmonary embolism, as recommended by the 2019 ESC guidelines 1. In terms of long-term management, therapeutic anticoagulation for more than 3 months is recommended for all patients with pulmonary embolism, with the option for extended oral anticoagulation of indefinite duration in certain cases, such as patients with recurrent VTE or those with a first episode of PE and no identifiable risk factor 1.

From the FDA Drug Label

1. 5 Acute PE in Hemodynamically Unstable Patients or Patients who Require Thrombolysis or Pulmonary Embolectomy Initiation of apixaban tablets are not recommended as an alternative to unfractionated heparin for the initial treatment of patients with PE who present with hemodynamic instability or who may receive thrombolysis or pulmonary embolectomy.

The patient is diagnosed with bilateral pulmonary embolism (PE) and is currently on a heparin infusion. Switching to Eliquis (apixaban) is not recommended as an initial treatment for patients with PE who are hemodynamically unstable or may require thrombolysis or pulmonary embolectomy. The FDA drug label does not provide guidance on how to switch a patient from heparin to apixaban in this specific scenario. 2

From the Research

Switching from Heparin to Eliquis (Apixaban)

To switch a patient with bilateral pulmonary embolism (PE) from a heparin infusion to Eliquis (apixaban), consider the following steps:

• Stop the heparin infusion and start apixaban at the recommended dose, which is typically 10 mg twice daily for the first 7 days, followed by 5 mg twice daily 3, 4.
• The decision to switch to apixaban should be based on the patient's clinical probability of PE, D-dimer testing, and chest imaging results 3.
• Apixaban is a direct oral anticoagulant (DOAC) that has been shown to be noninferior to heparin and warfarin for treating PE, with a lower rate of bleeding 3, 5.
• The duration of anticoagulation should be at least three months, and the decision to extend treatment should consider the individual risk of PE recurrence and bleeding 5, 6.

Key Considerations

• Apixaban has a rapid onset of action and predictable pharmacokinetics, allowing for a fixed-dose regimen without the need for initial parenteral anticoagulant therapy or laboratory monitoring 4, 6.
• Extended anticoagulation with apixaban has been shown to reduce the risk of recurrent venous thromboembolism without increasing the rate of major bleeding 6.
• The choice of anticoagulant agent and duration of treatment should be individualized based on the patient's clinical characteristics and risk factors 5, 7.

Clinical Evidence

• Studies have demonstrated the efficacy and safety of apixaban for the treatment of PE, including the AMPLIFY trial, which showed that apixaban was noninferior to enoxaparin and warfarin for the treatment of acute venous thromboembolism 4.
• The European Society of Cardiology (ESC) recommends the use of non-vitamin K antagonist oral anticoagulants (NOACs), such as apixaban, as the preferred treatment for PE in eligible patients 5.