When to transition a patient with pulmonary embolism from Lovenox (Enoxaparin) to Apixaban?

Transitioning from Lovenox to Apixaban in Pulmonary Embolism Management

For patients with pulmonary embolism (PE), transition from Lovenox (enoxaparin) to apixaban by starting apixaban at 10 mg twice daily for 7 days, then continuing with 5 mg twice daily, with the first dose of apixaban given at the time when the next dose of Lovenox would have been scheduled. 1, 2

Timing of Transition

The transition from parenteral anticoagulation to oral anticoagulation should follow these principles:

• For apixaban specifically:
  • Discontinue Lovenox and begin apixaban at the time when the next scheduled dose of Lovenox would have been administered 1, 2
  • No overlap period is required when transitioning from Lovenox to apixaban 3
  • Apixaban can be used as a single-drug regimen without the need for LMWH lead-in period 3

Dosing Protocol for Apixaban

• Initial treatment phase:

  • Apixaban 10 mg twice daily for the first 7 days 1, 2
  • Then reduce to 5 mg twice daily for continued treatment 2

• Dose adjustments:

  • Consider reduced dose of 2.5 mg twice daily for patients with at least two of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 2
  • For patients with severe renal impairment (CrCl <30 mL/min), DOACs should be avoided 1

Special Considerations

• Contraindications to apixaban:

  • Active pathological bleeding 2
  • Severe hypersensitivity to apixaban 2
  • Severe renal impairment (CrCl <30 mL/min) 1
  • Antiphospholipid antibody syndrome 3, 1

• Drug interactions:

  • For patients on combined P-gp and strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, ritonavir), reduce apixaban dose by 50% 2
  • If patient is already on 2.5 mg twice daily, avoid coadministration with these inhibitors 2

Monitoring After Transition

• No routine coagulation monitoring is required for patients on apixaban 1
• Assess for signs and symptoms of bleeding 2
• Evaluate drug tolerance, adherence, hepatic and renal function, and bleeding risk at regular intervals 3
• Routinely re-evaluate patients 3-6 months after the acute PE episode 1

Clinical Benefits of Early Transition

• Transitioning to apixaban may be associated with shorter hospital length of stay compared to traditional LMWH-to-warfarin transition 3
• The 2019 ESC guidelines recommend NOACs (including apixaban) over vitamin K antagonists for eligible patients with PE 3, 1

Common Pitfalls to Avoid

• Do not double-dose apixaban if a dose is missed; take the missed dose as soon as possible on the same day and resume the regular twice-daily schedule 2
• Do not use apixaban in pregnancy or lactation 3
• Do not abruptly discontinue apixaban without appropriate alternative anticoagulation due to increased risk of thrombotic events 2
• Do not use NOACs in patients with severe renal impairment or antiphospholipid antibody syndrome 3

By following these guidelines, you can safely and effectively transition patients from Lovenox to apixaban for PE treatment, optimizing outcomes while minimizing risks of recurrent thromboembolism and bleeding complications.