What is the recommended timing for transitioning a patient from heparin (Heparin Sodium) gtt (intravenous infusion) to Eliquis (Apixaban) at home?

Timing of Transitioning from Heparin GTT to Home Dose Eliquis

When transitioning from heparin infusion to apixaban (Eliquis), stop the heparin infusion and administer the first dose of apixaban immediately upon discontinuation of the heparin drip, without any overlap period. 1

Rationale for Timing

The transition from parenteral anticoagulation to oral anticoagulants requires careful timing to maintain adequate anticoagulation while minimizing bleeding risk. For apixaban specifically:

• Heparin has a short half-life (approximately 60-90 minutes) and its anticoagulant effect diminishes rapidly after discontinuation
• Apixaban reaches peak plasma levels within 3-4 hours after oral administration
• The immediate administration of apixaban after stopping heparin provides continuous anticoagulation coverage without significant gaps or excessive overlap

Specific Transition Protocol

1. Stop the heparin infusion completely
2. Administer the first dose of apixaban immediately upon discontinuation of the heparin infusion
3. Do not overlap the two medications as this increases bleeding risk without providing additional thrombotic protection

Dosing Considerations for Apixaban

The appropriate dosing of apixaban depends on the indication:

• For VTE treatment: 10 mg twice daily for the first 7 days, followed by 5 mg twice daily
• For atrial fibrillation: 5 mg twice daily (or 2.5 mg twice daily if patient meets at least two of these criteria: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL)

Special Considerations

Renal Function

• For patients with CrCl <15 mL/min, apixaban should be used with caution or avoided
• No dose adjustment is needed for mild to moderate renal impairment

Heparin-Induced Thrombocytopenia (HIT)

• In patients with HIT, transitioning to apixaban is appropriate once platelet counts have stabilized or begun to recover 1
• For acute HIT (<1 month), consider using argatroban or bivalirudin as a bridge before transitioning to apixaban 1

High Thrombotic Risk

• For patients at high thrombotic risk (recent thrombosis, mechanical heart valves), ensure minimal gap in anticoagulation during transition

Monitoring During Transition

• Monitor for signs of bleeding or thrombosis during the transition period
• No routine laboratory monitoring is required for apixaban therapy
• Platelet count monitoring is recommended if transitioning due to HIT until counts normalize

Common Pitfalls to Avoid

1. Premature discontinuation of heparin before apixaban reaches therapeutic levels
2. Unnecessary overlap of heparin and apixaban, increasing bleeding risk
3. Delayed initiation of apixaban after heparin discontinuation, creating a gap in anticoagulation
4. Failure to adjust dosing based on indication or patient-specific factors

By following this protocol, patients can be safely transitioned from heparin infusion to apixaban therapy with minimal risk of thrombotic or bleeding complications.