Bridging Lovenox (Enoxaparin) with Eliquis (Apixaban)
When transitioning from enoxaparin (Lovenox) to apixaban (Eliquis), no overlap or bridging period is required - simply discontinue enoxaparin and start apixaban at the scheduled time of the next enoxaparin dose. 1
General Principles for Transitioning
- Direct oral anticoagulants (DOACs) like apixaban have a rapid onset of action (2-4 hours), making traditional bridging unnecessary when transitioning from parenteral anticoagulants 1
- Unlike warfarin transitions, which require 5-7 days of overlap therapy, DOACs reach therapeutic levels quickly and do not require bridging 1
- Overlapping enoxaparin with apixaban increases bleeding risk without providing additional thrombotic protection 1
Specific Protocol for Transitioning
From Therapeutic-Dose Enoxaparin to Apixaban:
- For twice-daily enoxaparin (1 mg/kg or 1.5 mg/kg): Start apixaban at the time the next enoxaparin dose would have been due 1
- For once-daily enoxaparin (1.5 mg/kg): Start apixaban 12 hours after the last enoxaparin dose 1
- Initial apixaban dosing: Follow indication-specific loading doses (e.g., for DVT/PE: 10mg twice daily for 7 days, then 5mg twice daily) 2
From Prophylactic-Dose Enoxaparin to Apixaban:
- Start apixaban at the time the next prophylactic enoxaparin dose would have been scheduled 1
- No overlap period is needed 1
Special Considerations
- Renal function: Monitor closely as both medications are affected by renal impairment; apixaban requires dose adjustment with severe renal impairment 1
- High thrombotic risk patients: In rare cases of extremely high thrombotic risk, a multidisciplinary approach involving hematology/cardiology may be warranted 1
- Bleeding risk: Assess bleeding risk before transitioning; consider delaying apixaban initiation if active bleeding is present 1
- Neuraxial anesthesia: If transitioning in perioperative setting with epidural catheter in place, follow specific protocols for catheter removal before initiating therapeutic anticoagulation 1
Common Pitfalls to Avoid
- Unnecessary bridging: Unlike warfarin transitions, DOACs like apixaban do not require bridging with enoxaparin due to their rapid onset of action 1
- Medication overlap: Overlapping enoxaparin with apixaban significantly increases bleeding risk without additional thrombotic protection 1
- Incorrect timing: Starting apixaban too soon after enoxaparin can lead to excessive anticoagulation and bleeding risk 1
- Inadequate patient education: Ensure patients understand the importance of timing and proper administration of apixaban (twice daily dosing) 1, 2
By following these guidelines, you can safely transition patients from enoxaparin to apixaban while minimizing both thrombotic and bleeding risks.