What is the alternate intravenous (IV) therapeutic form of Eliquis (apixaban) for a patient who is nil per os (NPO)?

Intravenous Anticoagulation Alternatives for Patients on Apixaban Who Are NPO

For patients on oral apixaban (Eliquis) who become NPO, unfractionated heparin (UFH) is the preferred intravenous alternative anticoagulant.

First-Line IV Alternative to Apixaban

Unfractionated Heparin (UFH)

• Dosing options:
  • IV 80 units/kg bolus, followed by 18 units/kg/h adjusted to target aPTT of 2-2.5 times control 1
  • Alternative dosing: SC 333 units/kg load, followed by 250 units/kg every 12 hours 1
• Monitoring: Adjust dose to maintain aPTT 2-2.5 times baseline
• Advantages: Immediate onset, short half-life, reversible with protamine if needed
• Contraindications: Absolute contraindication in recent/acute heparin-induced thrombocytopenia (HIT); relative contraindication in past history of HIT 1

Second-Line IV Alternatives

Low Molecular Weight Heparin (LMWH)

• Options:
  • Dalteparin: 200 units/kg SC daily 1
  • Enoxaparin: 1 mg/kg SC every 12 hours 1
• Caution: Use with care in renal dysfunction; consider dose adjustments or alternative therapy for severe renal dysfunction (CrCl <30 mL/min) 1
• Monitoring: Anti-Xa monitoring may be needed for patients with severe renal dysfunction 1

Fondaparinux

• Dosing:
  • 5 mg SC daily (<50 kg)
  • 7.5 mg SC daily (50-100 kg)
  • 10 mg SC daily (>100 kg) 1
• Contraindication: CrCl <30 mL/min 1
• Caution: Use carefully in moderate renal insufficiency (CrCl 30-50 mL/min), weight <50 kg, or age >75 years 1

Alternative Options in Special Circumstances

Direct Thrombin Inhibitors (for patients with HIT)

• Argatroban:

  • IV continuous infusion: 0.5-1.2 μg/kg/min 1
  • Monitoring: Adjust to aPTT 1.5-3.0 times baseline 1
  • Advantage: No renal elimination, suitable for patients with renal impairment

• Bivalirudin:

  • IV continuous infusion: 1.5 mg/dL 1
  • Monitoring: Adjust to aPTT 1.5-2.5 times baseline 1

Clinical Decision-Making Algorithm

1. Assess patient factors:

   • Renal function (CrCl)
   • History of HIT
   • Bleeding risk
   • Expected duration of NPO status

2. Choose appropriate agent:

   • Normal renal function: UFH (first choice)
   • Renal impairment (CrCl <30 mL/min): UFH (preferred) or argatroban
   • History of HIT: Argatroban or bivalirudin
   • Short-term NPO (e.g., perioperative): UFH (due to short half-life)

3. Monitor appropriately:

   • UFH: aPTT every 6 hours initially, then daily when stable
   • LMWH: Anti-Xa levels if severe renal impairment or extremes of body weight
   • Direct thrombin inhibitors: aPTT monitoring

Important Considerations and Pitfalls

• NPO status assessment: Determine if patient can take medications with small sips of water despite NPO status
• Avoid interruption: Begin parenteral anticoagulation promptly when stopping apixaban to prevent gaps in anticoagulation coverage
• Transition planning: Have a clear plan for transitioning back to oral apixaban once NPO status is resolved
• Monitoring: Regular assessment of renal function is essential, especially with LMWH and fondaparinux
• Common pitfall: Failing to adjust UFH dosing based on aPTT results, leading to under- or over-anticoagulation
• Bleeding management: Have reversal strategies readily available (protamine for heparin, idarucizumab for dabigatran)

When the patient is able to resume oral intake, apixaban can be restarted at the previous dose without overlap with the parenteral agent, as apixaban has a rapid onset of action.