What anticoagulation should be used instead of Eliquis (apixaban) in a patient on the transplant list?

From the Guidelines

For patients on a transplant list who cannot use Eliquis (apixaban), low molecular weight heparin (LMWH) such as enoxaparin (Lovenox) is the preferred alternative anticoagulant. The standard therapeutic dose of enoxaparin is 1 mg/kg twice daily or 1.5 mg/kg once daily, with dose adjustments needed for renal impairment 1. LMWH is preferred because it has a shorter half-life than oral anticoagulants, allowing for easier management around transplant surgery, and it can be reversed with protamine sulfate if urgent surgery becomes available.

Some key points to consider when choosing an anticoagulant in this context include:

• The ability to easily manage and reverse the anticoagulant around the time of transplant surgery
• The potential for interactions with immunosuppressive medications that will be needed post-transplant
• The risk of bleeding and other complications associated with different anticoagulants

In some cases, unfractionated heparin may be used, especially for inpatients or those with severe renal dysfunction, typically administered as a continuous IV infusion with a target aPTT of 1.5-2.5 times normal 1. Warfarin is generally avoided in transplant candidates due to its long half-life, numerous drug interactions, and difficulty in rapid reversal. Any anticoagulation choice should be made in consultation with both the transplant team and hematology specialists to ensure the approach aligns with the specific transplant protocol.

It's also worth noting that the most recent guidelines from the National Comprehensive Cancer Network (NCCN) suggest that LMWH is a preferred option for patients with gastric or gastroesophageal lesions, and that apixaban may be safer than edoxaban or rivaroxaban for these patients 1. However, in the context of transplant patients, the preference for LMWH is driven by its pharmacokinetic properties and the need for easy reversibility, rather than concerns about gastric or gastroesophageal lesions.

From the Research

Alternatives to Eliquis (Apixaban) for Anticoagulation in Transplant Patients

• The choice of anticoagulant in patients on the transplant list can be complex, and there is limited evidence to guide the selection of alternatives to Eliquis (apixaban) 2, 3, 4.
• Some studies suggest that other direct-acting oral anticoagulants (DOACs) may be safe and effective alternatives to apixaban in solid organ transplant recipients, but the evidence is largely based on single-center retrospective analyses 3.
• Warfarin is another option for anticoagulation in transplant patients, and some studies have compared its safety and efficacy to DOACs in this population 4.
• A meta-analysis of 489 patients found that DOACs were associated with a decreased risk of composite bleed compared to warfarin, but there were no differences in rates of major bleeding or venous thromboembolism between the two groups 4.
• In patients with advanced chronic kidney disease, apixaban may be a reasonable alternative to warfarin, with similar efficacy and a potentially superior safety profile 5.
• However, the use of apixaban has been associated with anticoagulant-related nephropathy, and monitoring of kidney function is recommended after initiation of anticoagulant therapy 6.

Considerations for Anticoagulant Selection

• The selection of an anticoagulant in transplant patients should take into account individual patient factors, such as kidney function, drug-drug interactions, and the risk of bleeding 3, 5.
• Clinicians should consider the available evidence and consult with specialists in transplantation and anticoagulation to determine the best course of treatment for each patient 2, 3, 4.