What is the 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 time the next dose of heparin would have been administered, with no overlap period required.

Protocol for Transition

Standard Transition Protocol

• For intravenous (IV) heparin infusion:

  • Stop IV heparin infusion immediately
  • Start apixaban at the time the next scheduled dose of heparin would have been given
  • No overlap period is required 1

• For subcutaneous heparin:

  • Discontinue subcutaneous heparin
  • Administer first dose of apixaban at the time the next subcutaneous heparin dose would have been scheduled

Dosing Considerations for Apixaban

The appropriate apixaban dose depends on the indication:

• For DVT/PE treatment:

  • Initial dose: 10 mg twice daily for the first 7 days
  • Maintenance dose: 5 mg twice daily thereafter 1

• For atrial fibrillation:

  • Standard dose: 5 mg twice daily
  • Reduced dose (2.5 mg twice daily) for patients with at least two of:
    • Age ≥80 years
    • Body weight ≤60 kg
    • Serum creatinine ≥1.5 mg/dL 2, 1

Special Considerations

Monitoring Requirements

• Unlike heparin, apixaban does not require routine coagulation monitoring
• No need for aPTT or anti-Xa level monitoring once transitioned to apixaban
• Laboratory testing is generally not necessary during the transition 2

Timing Considerations

• For patients with heparin-induced thrombocytopenia (HIT), ensure platelet counts have stabilized before transitioning to apixaban 3
• For patients undergoing procedures, apixaban should be discontinued:
  • 24 hours before low bleeding risk procedures
  • 3 days before high bleeding risk procedures 2, 4

Contraindications and Cautions

• Avoid apixaban in patients with:
  • Severe renal impairment (CrCl <15 mL/min)
  • Active liver disease
  • Pregnancy or lactation 2
• Use with caution in patients taking medications that are strong dual inhibitors of CYP3A4 and P-glycoprotein, as these may increase bleeding risk 2

Practical Approach to Transition

1. Assess patient's indication for anticoagulation and determine appropriate apixaban dosing
2. Stop heparin without tapering
3. Administer first dose of apixaban at the time when next heparin dose would have been given
4. Educate patient about:
   • No need for routine laboratory monitoring
   • Importance of medication adherence (twice daily dosing)
   • Signs of bleeding to watch for
   • Avoiding other medications that increase bleeding risk without medical consultation

Common Pitfalls to Avoid

• Overlapping anticoagulants: Unlike transitioning to warfarin, no overlap period is needed when switching from heparin to apixaban 1
• Monitoring confusion: Avoid unnecessary coagulation tests after transition to apixaban
• Dose errors: Ensure correct dosing based on indication and patient characteristics
• Drug interactions: Assess for medications that may interact with apixaban, particularly strong CYP3A4 and P-glycoprotein inhibitors 2

This straightforward approach to transitioning from heparin to apixaban provides effective anticoagulation while minimizing the risk of both thrombotic and bleeding complications.