When should a patient with DVT start taking Eliquis (apixaban) after stopping a heparin (unfractionated heparin) drip?

Switching from Heparin to Apixaban (Eliquis) for DVT Treatment

Apixaban (Eliquis) should be started immediately after stopping the heparin infusion with no overlap or gap between therapies for patients with DVT. 1

Dosing Regimen for Apixaban in DVT Treatment

When transitioning from heparin to apixaban for DVT treatment, follow this protocol:

• Initial dosing: Start with apixaban 10 mg twice daily for the first 7 days
• Maintenance dosing: Continue with apixaban 5 mg twice daily after the initial 7-day period 1

Timing of Transition

The transition from heparin to apixaban should be managed as follows:

1. Stop the heparin infusion
2. Start apixaban immediately (within 0-2 hours) after discontinuing the heparin infusion
3. No overlap period is needed between heparin and apixaban therapy

This immediate transition is possible because:

• Apixaban has a rapid onset of action (1-3 hours to reach peak plasma concentration)
• Unfractionated heparin has a short half-life (approximately 60-90 minutes)
• There is no need for bridging therapy between these agents 2

Evidence Supporting This Approach

The immediate transition from heparin to direct oral anticoagulants (DOACs) like apixaban is supported by guidelines and clinical practice. Unlike the transition to warfarin, which requires 5-7 days of overlap with heparin, DOACs provide immediate therapeutic anticoagulation 1, 2.

Special Considerations

Renal Function

• Assess renal function before starting apixaban
• Standard dosing is appropriate for patients with CrCl >30 mL/min
• For patients with severe renal impairment (CrCl 15-29 mL/min), consider dose adjustment 1

Bleeding Risk

• Evaluate bleeding risk before transitioning
• In patients with high bleeding risk, ensure heparin effect has diminished before starting apixaban
• Consider checking aPTT if concerned about residual heparin effect 2

Monitoring

• No routine coagulation monitoring is required for apixaban, unlike heparin which requires aPTT monitoring
• Clinical monitoring for signs of bleeding or recurrent thrombosis is recommended 1

Common Pitfalls to Avoid

1. Unnecessary delay in starting apixaban after stopping heparin, which may increase thrombosis risk
2. Prolonged overlap between heparin and apixaban, which may increase bleeding risk
3. Failure to use the correct initial dosing of apixaban (10 mg twice daily for first 7 days)
4. Not considering patient-specific factors such as renal function, weight, or concomitant medications

Duration of Therapy

For patients with DVT:

• Minimum treatment duration is 3 months
• Consider extended therapy (beyond 3 months) for unprovoked DVT or patients with ongoing risk factors
• Annual reassessment of continued need for anticoagulation is recommended for those on extended therapy 1, 3

Following these guidelines will ensure a safe and effective transition from heparin to apixaban therapy for patients with DVT, minimizing both thrombotic and bleeding risks.