When to start Eliquis (apixaban) in a patient with pulmonary embolism already on a treatment dose of Lovenox (enoxaparin)?

Transitioning from Lovenox to Eliquis in Pulmonary Embolism Treatment

For patients with pulmonary embolism already on treatment dose of Lovenox (enoxaparin), Eliquis (apixaban) should be started directly or after 1-2 days of Lovenox administration, with an initial dose of 10 mg twice daily for 7 days, followed by 5 mg twice daily.

Timing of Transition

The European Society of Cardiology (ESC) guidelines provide clear direction on transitioning from parenteral anticoagulants to direct oral anticoagulants (DOACs) like apixaban:

• Apixaban can be started directly or after 1-2 days of parenteral anticoagulation with Lovenox 1
• When transitioning to apixaban, the acute-phase treatment consists of an increased dose for the first 7 days 1, 2

Dosing Protocol for Apixaban

The FDA-approved dosing regimen for apixaban in pulmonary embolism is:

• Initial dose: 10 mg taken orally twice daily for the first 7 days
• Maintenance dose: 5 mg taken orally twice daily after the initial 7 days 3, 2

Implementation Steps

1. Discontinue Lovenox: Stop Lovenox (enoxaparin) when starting apixaban
2. Start Apixaban: Begin apixaban at the 10 mg twice daily dose
3. Transition Timing: Administer the first dose of apixaban at the time when the next dose of Lovenox would have been scheduled 3
4. No Overlap Required: Unlike transitioning to warfarin, no overlap period is necessary when switching from Lovenox to apixaban 3

Special Considerations

• Renal Function: Assess renal function before initiating apixaban. In patients with severe renal impairment (creatinine clearance <30 mL/min), unfractionated heparin is preferred over Lovenox or apixaban 1, 2
• Bleeding Risk: Evaluate bleeding risk before transition. Apixaban should be discontinued at least 48 hours prior to elective surgery or invasive procedures with moderate/high bleeding risk 3
• Monitoring: Unlike heparin or warfarin, routine laboratory monitoring is not required for apixaban 2

Common Pitfalls to Avoid

• Dosing Error: Failing to use the higher initial dose (10 mg BID) for the first 7 days can lead to subtherapeutic anticoagulation
• Premature Discontinuation: Discontinuing apixaban prematurely increases thrombotic risk 3
• Overlap Confusion: Unlike warfarin transition (which requires overlap), Lovenox should be discontinued when apixaban is started
• Renal Function: Not accounting for renal function can increase bleeding risk in patients with impaired kidney function

Duration of Treatment

• Minimum treatment duration for PE is 3 months 2
• Extended anticoagulation beyond 3 months may be necessary based on:
  • Whether the PE was provoked by transient risk factors
  • Presence of persistent risk factors
  • History of recurrent venous thromboembolism 2

By following these guidelines, you can ensure a safe and effective transition from Lovenox to Eliquis in patients with pulmonary embolism, optimizing outcomes while minimizing risks.