How long after stopping heparin can I restart Eliquis (apixaban)?

Restarting Apixaban (Eliquis) After Heparin Discontinuation

Apixaban (Eliquis) can be restarted as soon as the heparin infusion has been discontinued, with no need for a waiting period between stopping heparin and starting apixaban. 1

Transitioning from Heparin to Apixaban

• According to the FDA drug label for apixaban, when switching from parenteral anticoagulants (such as heparin) to apixaban, discontinue the heparin and begin taking apixaban at the usual time of the next dose of the parenteral anticoagulant 1
• Unlike warfarin, which requires overlap with heparin until the INR reaches therapeutic range, direct oral anticoagulants (DOACs) like apixaban have a rapid onset of action and do not require bridging 2
• The pharmacokinetic properties of apixaban allow for immediate transition without a gap in anticoagulation coverage 1

Important Considerations When Restarting Apixaban

• Ensure adequate hemostasis has been established before restarting any anticoagulant, especially if heparin was stopped for a surgical or invasive procedure 1
• For patients who underwent surgery, apixaban should be restarted as soon as adequate hemostasis has been established, typically 6 hours after the end of the procedure if venous thromboprophylaxis is indicated 2
• For high bleeding risk procedures, a longer delay may be appropriate before restarting full-dose anticoagulation 2

Dosing Considerations When Restarting Apixaban

• For patients undergoing major surgery with high bleeding risk, consider resuming apixaban at a reduced dose (2.5 mg twice daily) for the first 2-3 days after surgery before increasing to the full therapeutic dose 2
• For patients undergoing less invasive procedures with lower bleeding risk, full-dose apixaban can typically be resumed the day after surgery, at least 24 hours after the procedure 2
• Standard dosing for apixaban is 5 mg twice daily for most patients with atrial fibrillation, with dose reduction to 2.5 mg twice daily for patients meeting specific criteria (age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL) 1

Special Considerations

• For patients at very high risk of thromboembolism (mechanical heart valves, recent thrombosis), a more aggressive approach to anticoagulation may be warranted 2
• If the patient has a history of heparin-induced thrombocytopenia (HIT), special precautions are needed, and anticoagulant treatment can typically be resumed from the 6th postoperative hour after assessment of bleeding risk 2
• Patients with renal impairment may require dose adjustments of apixaban, but unlike heparin, apixaban has less dependence on renal clearance (only 25%) 2

Common Pitfalls to Avoid

• Avoid unnecessary delays in restarting anticoagulation, as this increases thrombotic risk 2
• Do not overlap heparin and apixaban therapy, as this increases bleeding risk without providing additional antithrombotic benefit 1
• Remember that unlike transitioning between warfarin and heparin, no bridging or overlap period is required when switching between heparin and apixaban 1
• Monitor for signs of bleeding after restarting anticoagulation, especially in the first few days 2