When can a patient with acute pulmonary embolism (PE) be transitioned from a heparin drip to Eliquis (apixaban)?

Transitioning from Heparin Drip to Eliquis in Acute Pulmonary Embolism

For patients with acute pulmonary embolism, transition from heparin drip to apixaban (Eliquis) should occur after hemodynamic stability is achieved, with apixaban initiated at 10 mg twice daily for 7 days, followed by 5 mg twice daily, and the heparin drip discontinued when the first dose of apixaban is administered. 1, 2, 3

Timing of Transition

The transition from heparin to apixaban depends on the patient's clinical status:

• Hemodynamically unstable patients (systolic BP <90 mmHg):

  • Continue heparin drip until hemodynamic stability is achieved
  • Do not initiate apixaban as an alternative to unfractionated heparin for initial treatment 2
  • Consider thrombolysis if appropriate for these patients 1

• Hemodynamically stable patients:

  • Can be transitioned to apixaban once clinical stability is confirmed
  • No need to wait for a specific aPTT level before transitioning
  • Heparin can be discontinued at the time the first dose of apixaban is administered

Dosing Protocol for Transition

1. Initial apixaban dosing: 10 mg twice daily for 7 days
2. Maintenance dosing: 5 mg twice daily after the initial 7 days 1
3. Discontinue heparin: When the first dose of apixaban is administered (no overlap period required)

Patient Selection Considerations

Not all PE patients are candidates for immediate transition to apixaban:

• Contraindicated for immediate transition:

  • Patients with hemodynamic instability (systolic BP <90 mmHg)
  • Patients who may require thrombolysis or pulmonary embolectomy 2
  • Patients with triple-positive antiphospholipid syndrome 2
  • Patients with prosthetic heart valves 2

• Caution required:

  • Patients with severe renal impairment (CrCl <30 mL/min)
  • Patients at high risk of bleeding

Special Considerations

• Neuraxial anesthesia: If the patient has an epidural catheter, it should not be removed earlier than 24 hours after the last heparin dose, and apixaban should not be administered earlier than 5 hours after catheter removal 2

• Monitoring: Unlike heparin, apixaban does not require routine coagulation monitoring (PT, INR, or aPTT) 2

• Duration of therapy:

  • Secondary PE due to transient/reversible risk factors: 3 months
  • Unprovoked PE or persistent risk factors: Extended (>3 months)
  • Recurrent PE: Indefinite 1

Common Pitfalls to Avoid

1. Premature transition: Transitioning before hemodynamic stability is achieved in high-risk PE patients
2. Incorrect dosing: Failing to use the higher initial dose (10 mg BID) for the first 7 days
3. Unnecessary overlap: Creating an overlap period between heparin and apixaban, which increases bleeding risk
4. Inadequate patient selection: Transitioning patients who would benefit more from continued heparin therapy (e.g., those who may need thrombolysis)
5. Improper timing with epidural catheters: Not allowing sufficient time between anticoagulants and catheter manipulation

The transition from heparin to apixaban represents an important step in PE management that balances the need for effective anticoagulation with the benefits of oral therapy, including potential for earlier hospital discharge and improved quality of life 3, 4.