How to transition from heparin (Heparin) to oral apixaban (Eliquis) for treatment of Pulmonary Embolism (PE) and Deep Vein Thrombosis (DVT)?

From the Guidelines

To transition from heparin to Eliquis (apixaban) for pulmonary embolism (PE) and deep vein thrombosis (DVT), stop the heparin and immediately 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. This approach is supported by the guidelines, which suggest that oral anticoagulation with a non-vitamin K antagonist oral anticoagulant (NOAC) such as apixaban is preferred for patients with PE who are eligible for NOACs 1. The guidelines also recommend that therapeutic anticoagulation should be continued for more than 3 months for all patients with PE, and 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 1. It is also important to note that patients with severe renal impairment or antiphospholipid antibody syndrome should not be treated with NOACs, and that the patient's bleeding risk should be assessed and reassessed at regular intervals 1. For patients with renal impairment, a reduced dose of 2.5 mg twice daily may be considered after the initial 7-day treatment period, and patients with body weight less than 60 kg, age 80 years or older, or serum creatinine ≥1.5 mg/dL may also require the reduced dose of 2.5 mg twice daily for long-term treatment. The patient should take Eliquis with or without food at approximately the same times each day, and the transition approach works effectively because Eliquis directly inhibits Factor Xa in the coagulation cascade, providing immediate anticoagulation without requiring the antithrombin-mediated mechanism that heparin uses, allowing for a clean switch without the need for bridging therapy. Key considerations for the transition include:

• Stopping heparin and starting Eliquis immediately
• Using a dose of 10 mg twice daily for the first 7 days, followed by 5 mg twice daily for at least 3 months
• Considering a reduced dose of 2.5 mg twice daily for patients with renal impairment or other specific factors
• Assessing and reassessing the patient's bleeding risk at regular intervals
• Ensuring the patient takes Eliquis at approximately the same times each day, with or without food.

From the FDA Drug Label

2.4 Converting from or to apixaban Switching from warfarin to apixaban: Warfarin should be discontinued and apixaban started when the international normalized ratio (INR) is below 2. 0. There is no direct information in the label about transitioning from heparin to apixaban for treatment of Pulmonary Embolism (PE) and Deep Vein Thrombosis (DVT). The label only provides information about switching from warfarin to apixaban. Therefore, the information provided is not sufficient to determine how to transition from heparin to apixaban for the specified conditions. No conclusion can be drawn from the provided label regarding this specific transition 2.

From the Research

Transitioning from Heparin to Apixaban

To transition from heparin to oral apixaban for the treatment of Pulmonary Embolism (PE) and Deep Vein Thrombosis (DVT), the following steps can be considered:

• Discontinue heparin and start apixaban as soon as possible, as the risk of recurrent VTE is highest in the first few days after diagnosis 3
• The choice of anticoagulant should be based on the patient's individual risk factors, such as bleeding risk, renal function, and medication interactions 4, 3
• Apixaban is a direct-acting oral anticoagulant that has been shown to be effective in the treatment of VTE, with a lower risk of major bleeding compared to traditional anticoagulants 4, 5

Considerations for Transitioning

When transitioning from heparin to apixaban, the following considerations should be taken into account:

• The patient's renal function, as apixaban is contraindicated in patients with severe renal impairment 4, 3
• The patient's bleeding risk, as apixaban may increase the risk of bleeding in patients with a history of bleeding or who are taking concomitant medications that increase the risk of bleeding 4, 3
• The patient's medication interactions, as apixaban may interact with other medications, such as antiplatelet agents or other anticoagulants 4, 3

Monitoring and Follow-up

After transitioning to apixaban, the patient should be monitored regularly for signs and symptoms of recurrent VTE or bleeding, and the following should be considered:

• Regular follow-up appointments to monitor the patient's condition and adjust the treatment plan as needed 6, 5
• Laboratory tests, such as renal function tests and complete blood counts, to monitor for potential adverse effects of apixaban 4, 3
• Patient education on the signs and symptoms of recurrent VTE or bleeding, and the importance of adhering to the treatment plan 6, 5