What is the recommended dosing for transitioning a patient with atrial fibrillation (AFib) from a heparin (unfractionated heparin) drip to Eliquis (apixaban) at home?

Transitioning from Heparin Infusion to Apixaban in Patients with Atrial Fibrillation

When transitioning a patient with atrial fibrillation from an unfractionated heparin infusion to apixaban, discontinue the heparin infusion and begin apixaban immediately at the time the next dose of parenteral anticoagulant would have been administered. 1

Dosing Recommendations for Apixaban

Standard Dosing

• The recommended dose of apixaban for most patients with atrial fibrillation is 5 mg taken orally twice daily 2, 1
• No loading dose is required when transitioning from heparin to apixaban for routine management of atrial fibrillation

Dose Reduction Criteria

Reduce the dose to 2.5 mg twice daily if the patient has at least two of the following characteristics:

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

Transition Process

1. Stop heparin infusion without any overlap period
2. Start apixaban immediately at the time when the next dose of heparin would have been given
3. No bridging period is required between heparin and apixaban
4. No INR monitoring is needed when transitioning to apixaban (unlike warfarin transitions)

Special Considerations

Renal Function

• For patients with severe renal impairment (CrCl 15-29 mL/min), apixaban can still be used at the standard dose or reduced dose based on the criteria above 3, 4
• Apixaban is the only DOAC specifically mentioned in guidelines for potential use in dialysis patients, with a recommended dose of 2.5 mg twice daily 3

Bleeding Risk Assessment

• Assess bleeding risk before initiating apixaban
• Consider delaying the start of apixaban if the patient has active bleeding or is at high risk for immediate bleeding complications
• The risk of bleeding with apixaban is 31% lower compared to warfarin, making it a safer option for many patients 3

Patient Education for Home Use

When sending a patient home on apixaban:

• Instruct the patient to take apixaban exactly as prescribed, twice daily
• Emphasize that missing doses increases the risk of stroke
• If a dose is missed, take it as soon as remembered on the same day, but never double a dose
• Inform patients about bleeding signs to watch for
• Advise against stopping apixaban without consulting their healthcare provider
• Explain that no routine coagulation monitoring is required

Common Pitfalls to Avoid

• Inappropriate dose reduction: Only reduce the dose if the patient meets at least two of the three criteria 5, 6
• Overlap of anticoagulants: Do not administer apixaban with other anticoagulants due to increased bleeding risk
• Premature discontinuation: Stopping apixaban without medical advice increases thrombotic risk 1
• Failure to adjust for drug interactions: Be aware of interactions with strong CYP3A4 and P-glycoprotein inhibitors 3

Apixaban has demonstrated superior safety compared to warfarin with a 21% reduction in stroke or systemic embolism and 31% reduction in major bleeding, making it an excellent choice for anticoagulation in atrial fibrillation patients transitioning from heparin 3.