Apixaban Dosing Regimen When Switching from Enoxaparin
When switching from enoxaparin (Lovenox) to apixaban (Eliquis), the recommended initial dose is 10 mg twice daily for the first 7 days, followed by 5 mg twice daily for continued treatment. 1, 2
Timing of Transition
- Discontinue enoxaparin and start apixaban at the time the next scheduled dose of enoxaparin would have been due
- Unlike some other DOACs (dabigatran, edoxaban), apixaban does not require an overlap period with parenteral anticoagulation 1
- No bridging period is needed between enoxaparin and apixaban
Dosing Considerations
Standard Dosing for VTE Treatment
- Initial treatment phase: 10 mg orally twice daily for 7 days
- Maintenance phase: 5 mg orally twice daily thereafter 1
Dose Adjustments
- After ≥6 months of initial therapy, consider reducing to 2.5 mg twice daily for extended secondary prevention of VTE 1
- Reduce dose to 2.5 mg twice daily if patient has at least two of the following:
- Age ≥80 years
- Body weight ≤60 kg
- Serum creatinine ≥1.5 mg/dL 2
Special Populations
Renal Function
- Severe renal impairment (CrCl <15 mL/min): Avoid apixaban
- Moderate renal impairment (CrCl 15-30 mL/min): Use with caution 2
- Regular assessment of renal function is recommended:
- At least yearly in stable patients
- More frequently during acute illness, dehydration, or hospitalization 2
Drug Interactions
- For patients taking strong dual inhibitors of CYP3A4 and P-glycoprotein:
- Consider alternative medication or reduce apixaban dose by 25% 2
- Concurrent use with antiplatelet agents, NSAIDs, SSRIs, or SNRIs increases bleeding risk 2
Efficacy and Safety Considerations
- Apixaban has demonstrated non-inferiority to conventional therapy (enoxaparin followed by warfarin) for VTE treatment 3
- Major bleeding occurs less frequently with apixaban (0.6%) compared to conventional therapy (1.8%) 3
- For cancer patients, LMWH may be preferred over apixaban, though apixaban is an acceptable alternative 1, 2
Monitoring
- Routine coagulation monitoring is not required
- Monitor for signs of bleeding:
- Unexplained bruising
- Blood in urine or stool
- Unusual headaches or dizziness 2
- Assess renal function before starting apixaban and periodically during treatment
Common Pitfalls to Avoid
- Incorrect timing of transition (avoid overlap between enoxaparin and apixaban)
- Inappropriate dose reduction in patients without qualifying criteria
- Failure to consider drug interactions that may increase bleeding risk
- Overlooking the need for dose adjustment in patients with renal impairment
- Using the atrial fibrillation dosing regimen instead of the VTE treatment regimen
Following this dosing regimen will help ensure effective anticoagulation while minimizing bleeding risk when transitioning from enoxaparin to apixaban.