What is the recommended dose of Eliquis (apixaban) for patients transitioning from a heparin drip to home after surgery?

Transitioning from Heparin Drip to Apixaban Post-Surgery

For patients transitioning from a heparin drip to home after surgery, apixaban should be started at the full therapeutic dose of 5 mg twice daily once adequate hemostasis has been established, typically 24 hours after low bleeding risk procedures and 48-72 hours after high bleeding risk procedures. 1

Dosing Recommendations

Standard Dosing

• Atrial fibrillation: 5 mg twice daily 1, 2
• VTE treatment: 10 mg twice daily for 7 days, followed by 5 mg twice daily 2
• VTE prophylaxis after orthopedic surgery: 2.5 mg twice daily 2
• Extended VTE prevention: 2.5 mg twice daily 2

Dose Reduction Criteria

Reduce to 2.5 mg twice daily if the patient has at least 2 of the following:

• Age ≥80 years
• Body weight ≤60 kg
• Serum creatinine ≥1.5 mg/dL 1, 2, 3

Transition Protocol from Heparin to Apixaban

1. Discontinue heparin infusion without a taper
2. Start apixaban at the appropriate therapeutic dose (based on indication) at the time the next dose of heparin would have been given 2
3. No overlap period is required between heparin and apixaban 2

Timing of Apixaban Initiation Post-Surgery

The timing depends on the bleeding risk of the procedure:

Low Bleeding Risk Procedures

• Resume apixaban at full therapeutic dose 24 hours after surgery 4, 1
• No need for bridging with prophylactic doses 1

High Bleeding Risk Procedures

• Resume apixaban at full therapeutic dose 48-72 hours after surgery 4, 1
• If thrombotic risk is high, consider:
  • Using a reduced dose (2.5 mg twice daily) for the first 1-2 days 4
  • Starting prophylactic dose heparin/LMWH 6-12 hours post-surgery until apixaban can be safely initiated 4

Special Considerations

Renal Function

• Apixaban has lower renal clearance (27%) compared to other DOACs like dabigatran (80%), making it more predictable in patients with moderate renal impairment 1
• No dose adjustment needed for mild to moderate renal impairment 2

Monitoring Requirements

• No routine coagulation monitoring is required 1
• Monitor for signs of bleeding:
  • Check procedure site every 30 minutes initially 1
  • Monitor vital signs (pulse, blood pressure) regularly 1

Post-Discharge Instructions

• Avoid strenuous physical activities for at least 48 hours 1
• Avoid lifting weights greater than 10-15 pounds for at least 24 hours 1
• Watch for signs of bleeding (excessive bright red bleeding, blood in stool) 1

Common Pitfalls and Caveats

1. Avoid inappropriate dose reduction: Studies show that approximately 43% of patients receiving reduced-dose apixaban don't meet criteria for dose reduction 5. Using the full dose when appropriate is important for optimal efficacy.

2. No bridging needed: Unlike warfarin, apixaban does not require bridging with heparin during transitions, which can increase bleeding risk without additional benefit 1.

3. Timing is critical: Starting apixaban too early after surgery increases bleeding risk, while starting too late increases thrombotic risk. Follow the guidelines based on procedure bleeding risk 4, 1.

4. Drug interactions: Be aware of potential interactions with strong dual inhibitors of CYP3A4 and P-gp (e.g., ketoconazole), which may require dose adjustments 1.

5. Missed doses: If a dose is missed, take it as soon as possible on the same day and resume the normal schedule. Do not double the dose to make up for a missed dose 2.

By following these guidelines, patients can be safely transitioned from a heparin drip to apixaban therapy after surgery, minimizing both thrombotic and bleeding risks.