When is it okay to bridge from enoxaparin (Lovenox) to apixaban (Eliquis)?

Bridging from Enoxaparin (Lovenox) to Apixaban (Eliquis)

When surgical hemostasis is achieved and there is no epidural catheter present, the first therapeutic dose of apixaban (Eliquis) should be administered 12 hours after the last prophylactic dose of enoxaparin (Lovenox). 1

Timing of Transition

The timing of transitioning from enoxaparin to apixaban depends on several key factors:

1. Standard transition timing:

   • Administer the first dose of apixaban 12 hours after the last prophylactic dose of enoxaparin 1
   • For patients on therapeutic enoxaparin, start apixaban at the time the next dose of enoxaparin would have been taken 2

2. Post-surgical considerations:

   • Ensure adequate surgical hemostasis before initiating therapeutic anticoagulation
   • Therapeutic anticoagulation can typically be resumed between 24-72 hours postoperatively 1
   • Avoid overlapping anticoagulant effects to minimize bleeding risk 1

Dosing Considerations for Apixaban

The appropriate dose of apixaban depends on the indication:

• Venous thromboembolism (VTE) treatment:

  • Initial treatment: 10 mg twice daily for 7 days
  • Maintenance: 5 mg twice daily thereafter 2, 1

• Atrial fibrillation:

  • Standard dose: 5 mg twice daily
  • Reduced dose (2.5 mg twice daily) for patients with at least two of:
    • Age ≥80 years
    • Body weight ≤60 kg
    • Serum creatinine ≥1.5 mg/dL 2

Special Considerations and Precautions

High-Risk Scenarios Requiring Special Attention

1. Early phase of VTE:

   • During the initial phase of DVT/PE treatment when higher doses of apixaban are used (10 mg BID)
   • A personalized approach with multidisciplinary consultation is recommended 1

2. Renal function:

   • Monitor creatinine clearance, especially if the procedure may affect renal function
   • Adjust dosing accordingly 1

3. Drug interactions:

   • Reduce apixaban dose by 50% when co-administered with combined P-glycoprotein and strong CYP3A4 inhibitors 2

Epidural Catheters

• If an epidural catheter is present, therapeutic anticoagulation should be administered with heparin rather than apixaban until safe catheter withdrawal 1
• This precaution helps prevent epidural hematoma and potential neurological complications

Common Pitfalls to Avoid

1. Overlapping anticoagulant effects:

   • Avoid administering therapeutic doses of both medications simultaneously 1
   • Follow the recommended timing intervals to prevent excessive anticoagulation

2. Inadequate bridging in high-risk patients:

   • Patients with mechanical heart valves require special consideration and may need different bridging strategies 1
   • For patients with recent VTE (within 3 months), consider delaying elective procedures 1

3. Restarting too soon after surgery:

   • Ensure adequate hemostasis before restarting therapeutic anticoagulation
   • The timing should balance thrombotic and bleeding risks 1

Algorithmic Approach to Bridging

1. Assess patient's thrombotic risk:

   • High risk: Recent VTE (within 3 months), mechanical heart valve
   • Moderate risk: Atrial fibrillation with risk factors
   • Low risk: Atrial fibrillation without risk factors, VTE >3 months ago

2. Assess bleeding risk of procedure:

   • High risk: Major surgery, neuraxial anesthesia
   • Moderate risk: Procedures lasting >45 minutes
   • Low risk: Minor procedures

3. Determine appropriate timing:

   • For low bleeding risk: Minimal interruption of anticoagulation
   • For high bleeding risk: Ensure adequate time between last enoxaparin dose and procedure

4. Initiate apixaban:

   • After adequate hemostasis is achieved
   • 12 hours after the last prophylactic dose of enoxaparin
   • At the time the next dose of therapeutic enoxaparin would have been taken

By following this structured approach and considering both thrombotic and bleeding risks, the transition from enoxaparin to apixaban can be managed safely and effectively.