When do you transition from a heparin (unfractionated heparin) drip to Eliquis (apixaban) after catheterization?

Transitioning from Heparin Drip to Eliquis (Apixaban) After Catheterization

When surgical hemostasis is achieved and there are no bleeding complications, Eliquis (apixaban) can be started 24-72 hours after catheterization, with the first therapeutic dose administered 12 hours after the last prophylactic heparin dose. 1

Timing Considerations for Transition

The transition from unfractionated heparin (UFH) to apixaban should follow these guidelines:

1. Ensure hemostasis is achieved at the catheterization site
2. Wait at least 6 hours after the end of the invasive procedure before considering any anticoagulation
3. Assess bleeding risk of the specific catheterization procedure performed:
   • Low bleeding risk procedures: Resume apixaban 6-24 hours after procedure
   • High bleeding risk procedures: Delay apixaban for 24-72 hours

Specific Transition Protocol

• Stop heparin infusion without a specific reversal agent
• Wait 4-6 hours after heparin discontinuation (considering heparin's half-life of 1-2 hours)
• Start apixaban at the appropriate dose for the indication:
  • Atrial fibrillation: 5 mg BID (or 2.5 mg BID if ≥2 criteria: age ≥80 years, weight ≤60 kg, or creatinine ≥133 μmol/L) 1
  • VTE treatment: 10 mg BID for 7 days, then 5 mg BID 1

Special Considerations

Renal Function

• Monitor creatinine clearance postoperatively, especially if the procedure could affect renal function
• Adjust apixaban dosing accordingly if renal function is impaired

Bleeding Risk Assessment

• For patients with high bleeding risk, consider delaying apixaban initiation and using prophylactic doses of heparin or LMWH temporarily
• For patients with epidural catheters, therapeutic anticoagulation must be administered with heparin until safe catheter removal 1

Thrombotic Risk Assessment

• For patients at very high thrombotic risk, minimize the time without anticoagulation
• For patients in the early phase of venous thromboembolism treatment requiring high-dose apixaban (10 mg BID), a personalized approach should be discussed by a multidisciplinary team 1

Practical Implementation

• No bridging necessary: Unlike transitioning to warfarin, no overlapping period between heparin and apixaban is required 1
• Avoid overlapping: Do not administer apixaban while heparin is still active in the system
• First dose timing: If venous thromboprophylaxis with LMWH was used post-procedure, administer the first therapeutic dose of apixaban 12 hours after the last prophylactic LMWH dose 1

Common Pitfalls to Avoid

• Premature discontinuation of heparin before hemostasis is achieved
• Delayed initiation of apixaban increasing thrombotic risk
• Overlapping full-dose anticoagulants increasing bleeding risk
• Failure to adjust dosing based on patient characteristics and indication
• Inadequate monitoring of the catheterization site for bleeding after apixaban initiation

Following these guidelines will help ensure a safe and effective transition from heparin to apixaban after catheterization while minimizing both thrombotic and bleeding risks.