What is the recommended protocol for transitioning a patient from heparin to Eliquis (apixaban)?

Transitioning from Heparin to Apixaban (Eliquis)

When transitioning from heparin to apixaban, discontinue heparin and begin apixaban at the usual time of the next scheduled dose of heparin, with no overlap period required. 1

Protocol for Transitioning from Heparin to Apixaban

Step 1: Discontinuation of Heparin

• Stop intravenous unfractionated heparin (UFH) and begin apixaban at the time when the next dose of heparin would have been administered 1
• No bridging or overlap period is required between heparin and apixaban
• Ensure adequate hemostasis is established before initiating apixaban

Step 2: Dosing of Apixaban

The appropriate dose of apixaban depends on the indication:

• For VTE treatment: 10 mg twice daily for the first 7 days, followed by 5 mg twice daily 1, 2
• For atrial fibrillation: 5 mg twice daily (or 2.5 mg twice daily if patient has at least two of the following: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL) 1
• For VTE prophylaxis: 2.5 mg twice daily 1

Step 3: Timing Considerations

• For patients receiving intravenous UFH: Start apixaban when the heparin infusion is discontinued 1
• For patients receiving subcutaneous LMWH: Start apixaban 0-2 hours before the next scheduled dose of LMWH would have been given 2
• Avoid administering the next dose of LMWH if transitioning to apixaban

Step 4: Monitoring After Transition

• No routine coagulation monitoring is required for apixaban
• Monitor for signs and symptoms of bleeding
• Assess renal function, as impaired renal function may affect apixaban clearance

Special Considerations

Renal Function

• For patients with CrCl <15 mL/min, apixaban should be avoided 3
• For patients with CrCl 15-50 mL/min, apixaban is preferred over dabigatran 3
• No dose adjustment is required for mild to moderate renal impairment

Drug Interactions

• Reduce apixaban dose by 50% when co-administered with drugs that are combined P-gp and strong CYP3A4 inhibitors 1
• For patients already taking 2.5 mg twice daily, avoid co-administration with combined P-gp and strong CYP3A4 inhibitors 1

Temporary Interruptions

• If a surgical procedure is planned, apixaban should be discontinued:
  • At least 48 hours prior to elective surgery with moderate/high bleeding risk
  • At least 24 hours prior to procedures with low bleeding risk 1
• Restart apixaban as soon as adequate hemostasis has been established 1

Potential Pitfalls and Caveats

• Avoid premature discontinuation of anticoagulation as it increases risk of thrombotic events 1
• Do not double the dose to make up for a missed dose 1
• Concomitant use of drugs affecting hemostasis (aspirin, NSAIDs, other anticoagulants) increases bleeding risk 1
• Unlike transitioning to warfarin, no overlap period is needed when transitioning from heparin to apixaban 1
• Patients with gastric or gastroesophageal lesions may be at increased risk for hemorrhage with DOACs, including apixaban 2

By following this protocol, the transition from heparin to apixaban can be accomplished safely and effectively, minimizing the risk of both thrombotic and bleeding complications.