When to start apixaban (generic name for Eliquis) after the last dose of enoxaparin (low molecular weight heparin, LMWH)?

Timing of Apixaban After Enoxaparin Administration

Apixaban should be started 12 hours after the last dose of prophylactic enoxaparin or 24 hours after the last dose of therapeutic enoxaparin. 1

Evidence-Based Timing Recommendations

The timing of transitioning from enoxaparin to apixaban depends on the dosing regimen of enoxaparin:

For Prophylactic Dose Enoxaparin:

• Wait at least 12 hours after the last prophylactic dose of enoxaparin before initiating apixaban
• This timing minimizes the risk of excessive anticoagulation while maintaining therapeutic efficacy

For Therapeutic Dose Enoxaparin:

• Wait at least 24 hours after the last therapeutic dose of enoxaparin before initiating apixaban
• This is particularly important as therapeutic enoxaparin has been shown to have residual anti-Xa activity beyond 24 hours in some patients 2

Dosing Considerations for Apixaban Initiation

When starting apixaban after enoxaparin, use the appropriate loading dose based on the indication:

• For VTE treatment: Start with 10 mg twice daily for 7 days, followed by 5 mg twice daily 1
• For atrial fibrillation: Start with 5 mg twice daily (or 2.5 mg twice daily if the patient meets at least two of: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL) 1
• For VTE prophylaxis after orthopedic surgery: Use 2.5 mg twice daily 3

Special Considerations and Cautions

Renal Function

• Unlike warfarin, concurrent administration with parenteral anticoagulants is not recommended when transitioning to apixaban 1
• Apixaban is 27% renally excreted, so dose adjustment may be needed in severe renal impairment 4
• For patients with CrCl <15 mL/min, apixaban should be avoided 4

Bleeding Risk

• Monitor for signs of bleeding during the transition period
• The risk of major bleeding with apixaban is comparable to enoxaparin (0.7% vs 0.8%) 5
• Consider delaying the start of apixaban in patients who had significant intraoperative bleeding complications 1

Cancer Patients

• For cancer patients, LMWH is generally preferred over DOACs, though apixaban is an acceptable alternative 1
• If transitioning from enoxaparin to apixaban in cancer patients, follow the same timing guidelines as above

Practical Algorithm for Transitioning

1. Determine enoxaparin dosing regimen:

   • Prophylactic dose (e.g., 40 mg daily)
   • Therapeutic dose (e.g., 1 mg/kg twice daily or 1.5 mg/kg daily)

2. Calculate appropriate waiting period:

   • Prophylactic dose: Wait ≥12 hours after last dose
   • Therapeutic dose: Wait ≥24 hours after last dose

3. Determine appropriate apixaban starting dose based on indication (as outlined above)

4. Initiate apixaban after appropriate waiting period without overlapping with enoxaparin

5. Monitor patient for signs of bleeding or thrombosis during the transition period

By following these evidence-based recommendations, clinicians can optimize the transition from enoxaparin to apixaban while minimizing the risks of both thrombosis and bleeding.