Can a postoperative hip patient be given Lovenox (enoxaparin) in addition to their home medication Eliquis (apixaban)?

Concurrent Use of Lovenox and Eliquis in Postoperative Hip Patients

No, a postoperative hip patient should not receive both Lovenox (enoxaparin) and Eliquis (apixaban) concurrently due to significantly increased bleeding risk without additional thromboprophylactic benefit. 1

Rationale for Single Agent Approach

• Apixaban and enoxaparin are both anticoagulants that work primarily through factor Xa inhibition, making their concurrent use redundant and potentially dangerous 1
• Apixaban is an oral direct factor Xa inhibitor with 45% bioavailability and a half-life of 8-14 hours 1
• Enoxaparin is a low molecular weight heparin (LMWH) that predominantly inhibits factor Xa but also inhibits thrombin to some degree 2
• Combining these agents would significantly increase bleeding risk without providing additional VTE prevention benefit 1

Appropriate VTE Prophylaxis After Hip Surgery

Recommended Options (Choose One):

• Apixaban 2.5 mg orally twice daily starting 12-24 hours after surgery and continuing for 35 days 1
• Enoxaparin 40 mg subcutaneously once daily starting 12 hours before surgery or 12 hours after wound closure and continuing for 35 days 1

Comparative Efficacy and Safety:

• Apixaban has demonstrated superior efficacy to enoxaparin in preventing VTE after hip replacement surgery:
  • 1.4% VTE rate with apixaban vs. 3.9% with enoxaparin (relative risk 0.36) 2
  • Reduced symptomatic DVT by 59% compared to enoxaparin (RR 0.41) 1
• Bleeding risk is comparable between the two agents:
  • Major bleeding: 0.7% with apixaban vs. 0.8% with enoxaparin 3
  • Combined major and clinically relevant non-major bleeding: 4.8% with apixaban vs. 5.0% with enoxaparin 4

Management Algorithm for Patients on Home Apixaban

For a postoperative hip patient who was taking Eliquis (apixaban) at home:

1. Discontinue home apixaban before surgery according to institutional protocol (typically 24-48 hours before elective surgery) 1

2. Choose ONE postoperative anticoagulation strategy:

   • Option A: Resume apixaban 2.5 mg twice daily starting 12-24 hours after surgery 1, 4
   • Option B: Use enoxaparin 40 mg daily until the patient can resume oral medications, then transition back to the patient's home dose of apixaban 1

3. Do NOT administer both medications simultaneously as this would substantially increase bleeding risk without additional benefit 1

Special Considerations

• For patients with renal impairment, apixaban may be preferred as it has multiple elimination pathways (renal, hepatic, and intestinal) 1
• For patients with high bleeding risk, consider mechanical prophylaxis with intermittent pneumatic compression devices instead of or as a bridge to pharmacological prophylaxis 1
• Efficacy of apixaban appears consistent across subgroups of age, gender, body weight, BMI, and creatinine clearance 5

Common Pitfalls to Avoid

• Never combine two anticoagulants with similar mechanisms of action (such as apixaban and enoxaparin) 1
• Avoid starting apixaban too early after surgery (less than 12 hours) as this increases bleeding risk 4
• Do not abruptly switch between anticoagulants without appropriate overlap or transition periods 1
• Remember that bleeding risk assessment is complex and depends on multiple patient factors 1

By following these recommendations, you can provide effective VTE prophylaxis while minimizing bleeding risk in postoperative hip patients.