What is the protocol for converting a patient from Eliquis (apixaban) to Lovenox (enoxaparin)?

Converting from Apixaban (Eliquis) to Enoxaparin (Lovenox)

When converting a patient from Eliquis (apixaban) to Lovenox (enoxaparin), discontinue apixaban and begin enoxaparin at the time the next dose of apixaban would have been taken.

Conversion Protocol

Step 1: Discontinuation of Apixaban

• Stop apixaban completely
• Do not administer any further doses

Step 2: Timing of Enoxaparin Initiation

• Begin enoxaparin at the time when the next scheduled dose of apixaban would have been administered
• Do not overlap the medications to avoid increased bleeding risk

Step 3: Appropriate Enoxaparin Dosing

For standard therapeutic anticoagulation:

• For patients <75 years of age: 1 mg/kg subcutaneously every 12 hours
• For patients ≥75 years of age: 0.75 mg/kg subcutaneously every 12 hours without an initial IV bolus 1
• For patients with renal impairment (CrCl <30 mL/min): 1 mg/kg subcutaneously once daily 2

For specific clinical scenarios:

• For DVT/PE treatment: 1 mg/kg subcutaneously every 12 hours (preferred) or 1.5 mg/kg once daily 2
• For patients with BMI ≥40 kg/m²: Consider reduced dose of 0.8 mg/kg subcutaneously every 12 hours 2

Important Considerations

Monitoring Recommendations

• Complete blood count monitoring every 2-3 days during the first 2 weeks, then every 2 weeks or as clinically indicated 2
• Monitor platelet counts due to risk of heparin-induced thrombocytopenia
• Consider anti-Xa level monitoring in patients with severe renal insufficiency or other special populations

Potential Pitfalls

1. Avoid simultaneous administration: Never administer both medications simultaneously as this significantly increases bleeding risk 1
2. Renal function assessment: Always assess renal function before initiating enoxaparin and adjust dosing accordingly
3. Weight-based dosing: Ensure accurate weight measurement for proper dosing
4. Avoid switching between different anticoagulants: Patients initially treated with enoxaparin should not be switched to unfractionated heparin and vice versa because of increased risk of bleeding 1

Special Populations

• Cancer patients: May benefit from twice-daily dosing regimen (1 mg/kg every 12 hours) 2
• Elderly patients: Use reduced dosing (0.75 mg/kg every 12 hours) and monitor closely for bleeding complications 1
• Renal impairment: Adjust dose to 1 mg/kg once daily for CrCl <30 mL/min 2

This protocol ensures appropriate anticoagulation coverage while minimizing the risk of thrombotic events during the transition period. The direct switch approach (starting enoxaparin at the time of the next scheduled apixaban dose) provides the most straightforward and safest conversion method.