From the Guidelines
Patients with pulmonary embolism (PE) or deep vein thrombosis (DVT) can typically be transitioned from a heparin drip to Eliquis (apixaban) once they are hemodynamically stable and ready for discharge or transition to oral therapy, with the standard approach being to start Eliquis at 10 mg twice daily for the first 7 days, followed by 5 mg twice daily for at least 3 months, as recommended by the 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism 1. When transitioning, the heparin infusion should be discontinued at the time the first dose of Eliquis is administered, with no overlap period required. This direct transition is possible because Eliquis has a rapid onset of action and reaches therapeutic levels quickly. Some key considerations for transitioning to Eliquis include:
- Ensuring the patient has no contraindications to Eliquis, such as active major bleeding, severe renal impairment, or concurrent use of strong dual CYP3A4/P-gp inhibitors
- Assessing the patient's bleeding risk and renal function, as these may influence the decision to transition to Eliquis and the dose used 1
- Considering dose adjustments for patients with renal impairment, liver disease, age >80 years, or weight <60 kg The transition to oral therapy with Eliquis is advantageous as it eliminates the need for continuous IV access and frequent aPTT monitoring while providing predictable anticoagulation without routine laboratory monitoring. According to the American Society of Hematology 2020 guidelines for management of venous thromboembolism, the treatment of deep vein thrombosis and pulmonary embolism with apixaban is supported by randomized controlled trials 1. It's also important to note that extended oral anticoagulation of indefinite duration should be considered for patients with a first episode of PE and no identifiable risk factor, or for those with a first episode of PE associated with a persistent risk factor other than antiphospholipid antibody syndrome, and a reduced dose of apixaban (2.5 mg twice daily) may be considered after 6 months of therapeutic anticoagulation 1.
From the Research
Transitioning from Heparin Drip to Eliquis
When considering transitioning a patient with pulmonary embolism (PE) or deep vein thrombosis (DVT) from a heparin drip to Eliquis (apixaban), several factors must be taken into account.
- The patient's condition and response to initial heparin treatment
- The presence of any contraindications to apixaban
- The need for ongoing anticoagulation
Timing of Transition
According to the available evidence, the transition from heparin to apixaban can be considered after the patient has been stabilized on heparin and the international normalized ratio (INR) is within the therapeutic range 2.
- For patients with DVT or low-risk PE, treatment with low-molecular-weight heparin and a vitamin K antagonist (warfarin) or direct-acting oral anticoagulants can be initiated in the outpatient setting 2.
- Inpatient treatment of VTE typically begins with parenteral agents, preferably low-molecular-weight heparin, and can be transitioned to apixaban after the patient is stabilized 2.
Special Considerations
Certain patient populations may require special consideration when transitioning from heparin to apixaban, including:
- Patients with heparin-induced thrombocytopenia (HIT), who may be transitioned to apixaban after platelet counts have stabilized 3
- Patients with cancer, low or high body weight, or poor renal function, who may require closer monitoring and dose adjustments 4
Efficacy and Safety of Apixaban
Apixaban has been shown to be effective and safe for the treatment of VTE, with a favorable net clinical benefit compared to traditional anticoagulants 5, 4.
- Apixaban offers several advantages over historical therapy for the treatment and secondary prevention of VTE, including convenience and reduced risk of bleeding complications 4.