Does a patient on Eliquis (apixaban) require Venous Thromboembolism (VTE) prophylaxis with Lovenox (enoxaparin) upon admission?

From the Guidelines

Patients already on Eliquis (apixaban) for therapeutic anticoagulation generally do not need additional VTE prophylaxis with Lovenox (enoxaparin) when admitted to the hospital, as evidenced by the most recent guidelines from the Journal of Clinical Oncology 1. Eliquis is a direct oral anticoagulant (DOAC) that provides sufficient anticoagulation to prevent venous thromboembolism. Adding Lovenox would create redundant anticoagulation and significantly increase the risk of bleeding complications.

When a patient on Eliquis is admitted, the clinical team should continue the patient's home dose of Eliquis if the patient can take oral medications and has normal renal function. If the patient cannot take oral medications or has severe renal impairment, the team may need to temporarily switch to a parenteral anticoagulant like heparin or Lovenox at therapeutic (not prophylactic) dosing. The decision to continue or modify anticoagulation should be based on the patient's individual risk factors, including their bleeding risk, reason for admission, and planned procedures.

Key considerations include:

• The patient's indication for Eliquis therapy, such as atrial fibrillation, previous DVT/PE, or other conditions
• The patient's renal function, as Eliquis is contraindicated in severe renal impairment
• The patient's ability to take oral medications, as parenteral anticoagulants may be necessary in certain situations
• The need for bridging strategies if Eliquis must be held for procedures, as outlined in the guidelines from the Journal of Clinical Oncology 1 and supported by previous studies 1.

Overall, the goal is to balance the risk of thromboembolism with the risk of bleeding complications, and to individualize care based on the patient's unique needs and circumstances.

From the FDA Drug Label

The efficacy profile of apixaban was generally consistent across subgroups of interest for this indication (e.g., age, gender, race, body weight, renal impairment). Apixaban was shown to be noninferior to enoxaparin/warfarin in the AMPLIFY study for the primary endpoint of recurrent symptomatic VTE (nonfatal DVT or nonfatal PE) or VTE-related death over 6 months of therapy

Venous Thromboembolism (VTE) Prophylaxis is not directly addressed in the context of a patient already on Eliquis (apixaban). The information provided does not support a conclusion about the need for Lovenox (enoxaparin) as VTE prophylaxis for a patient on apixaban. Key Points:

• The studies described compare apixaban to enoxaparin/warfarin for treatment of DVT and PE, not for VTE prophylaxis in patients already on apixaban.
• There is no direct information provided about the use of enoxaparin as VTE prophylaxis for patients on apixaban. 2

From the Research

Venous Thromboembolism (VTE) Prophylaxis with Lovenox (enoxaparin) for Patients on Eliquis (apixaban)

• The need for VTE prophylaxis with Lovenox (enoxaparin) for patients on Eliquis (apixaban) is not clearly established in the provided studies.
• Studies have compared the efficacy and safety of apixaban with enoxaparin in preventing VTE, but the context of these studies is different from the question of whether a patient on apixaban requires additional VTE prophylaxis with enoxaparin upon admission.

Efficacy and Safety of Apixaban Compared to Enoxaparin

• A study published in 2016 3 found that apixaban was noninferior to enoxaparin/warfarin in the treatment of adults with acute VTE, with a lower risk of major bleeding.
• Another study from 2020 4 compared the effectiveness and safety of apixaban versus warfarin in patients with VTE and found that apixaban was associated with lower risks of recurrent VTE and major bleeding events.
• A 2016 study 5 found that apixaban resulted in a lower VTE incidence and fewer hemorrhagic complications compared to enoxaparin in patients undergoing total knee arthroplasty.
• The AMPLIFY trial, a randomized, double-blind comparison of oral apixaban with conventional therapy (enoxaparin followed by warfarin), found that apixaban was noninferior to conventional therapy in preventing recurrent VTE, with a lower risk of major bleeding 6.

Considerations for VTE Prophylaxis

• A 2011 study 7 found that extended prophylaxis with apixaban was not superior to short-term prophylaxis with enoxaparin in medically ill patients, and apixaban was associated with significantly more major bleeding events.
• The provided studies do not directly address the question of whether a patient on apixaban requires additional VTE prophylaxis with enoxaparin upon admission, and more research may be needed to determine the best approach in this scenario.