Is it okay to be on heparin and Eliquis (apixaban) simultaneously?

Simultaneous Use of Heparin and Apixaban

Concurrent use of heparin and apixaban (Eliquis) is generally not recommended due to the significantly increased risk of bleeding complications without additional antithrombotic benefit.

Rationale for Avoiding Concurrent Use

Heparin and apixaban are both anticoagulants that work through different mechanisms but produce similar clinical effects:

• Heparin acts by binding to antithrombin and enhancing its activity to inhibit thrombin and factor Xa
• Apixaban is a direct factor Xa inhibitor

Bleeding Risk

When used together, these medications create an additive or potentially synergistic anticoagulant effect that substantially increases bleeding risk:

• The American Heart Association guidelines note that treatment with GP IIb/IIIa antagonists plus heparin increases bleeding risk, requiring dose reductions 1
• Even when used alone, anticoagulants carry significant bleeding risk that requires careful management 1

Specific Clinical Scenarios

Transitioning Between Anticoagulants

When switching between these medications, sequential rather than concurrent use is recommended:

• When transitioning from heparin to apixaban, the first apixaban dose should be administered after discontinuing the heparin infusion 2
• If initial prophylaxis with LMWH is used, the first DOAC dose should be administered 12 hours after the last prophylactic LMWH dose 2
• Overlapping periods between heparin and apixaban should be avoided to prevent excessive bleeding risk 2

Special Circumstances

There are rare, specific clinical scenarios where temporary overlap might occur:

1. Bridging during procedures: Patients with epidural catheters may receive heparin for anticoagulation until safe catheter removal, after which DOAC initiation should occur 2

2. Acute coronary syndromes: In unstable angina/NSTEMI management, heparin may be used with GP IIb/IIIa inhibitors, but this is a different clinical scenario than concurrent use with apixaban 1

Common Errors to Avoid

• Premature initiation of DOACs before adequate hemostasis
• Overlapping full-dose anticoagulants
• Failure to adjust dosing based on patient characteristics
• Inadequate monitoring for bleeding complications 2

Conclusion

The simultaneous use of heparin and apixaban should be avoided in routine clinical practice due to the significantly increased risk of bleeding complications without proven additional benefit. When transitioning between these medications, ensure one agent is discontinued before initiating the other to minimize bleeding risk.