What dose of Lovenox (enoxaparin) should be taken while holding Eliquis (apixaban)?

Enoxaparin Dosing When Holding Apixaban

For patients who need to temporarily discontinue apixaban (Eliquis), the recommended bridging dose of enoxaparin (Lovenox) is 1 mg/kg subcutaneously twice daily for patients with normal renal function, or 1 mg/kg once daily for patients with creatinine clearance <30 mL/min. 1, 2

Dosing Considerations Based on Patient Factors

Standard Therapeutic Dosing

• For most patients with normal renal function, enoxaparin should be administered at 1 mg/kg subcutaneously every 12 hours when bridging from apixaban 1
• For patients weighing over 100 kg, consider using 1.5 mg/kg once daily instead of twice-daily dosing 1

Renal Function Adjustments

• For patients with severe renal impairment (creatinine clearance <30 mL/min), reduce the dose to 1 mg/kg subcutaneously once daily 1, 2
• Patients with moderate renal impairment (creatinine clearance 30-50 mL/min) should be monitored carefully for signs of bleeding, though standard dosing can typically be used 1

Age-Based Adjustments

• For patients ≥75 years old, use 0.75 mg/kg subcutaneously every 12 hours without an initial IV bolus 1, 2
• Elderly patients should be monitored more closely for signs of bleeding due to increased risk 2

Timing of Administration

When to Start Enoxaparin After Stopping Apixaban

• Apixaban has a half-life of approximately 12 hours in most patients 1
• Begin enoxaparin approximately 24 hours after the last dose of apixaban to minimize the risk of excessive anticoagulation 1
• For patients at high thrombotic risk, consider starting enoxaparin 12-24 hours after the last apixaban dose 2

When to Restart Apixaban After Enoxaparin

• For patients receiving twice-daily enoxaparin (1 mg/kg), restart apixaban 12 hours after the last enoxaparin dose 1
• For patients receiving once-daily enoxaparin (1.5 mg/kg), restart apixaban 24 hours after the last enoxaparin dose 1

Special Clinical Scenarios

Perioperative Management

• For low bleeding risk procedures, stop apixaban 24 hours before the procedure 1
• For high bleeding risk procedures, stop apixaban 48 hours before the procedure 1
• Begin therapeutic-dose enoxaparin bridging 24 hours after stopping apixaban if the thrombotic risk is high 2
• Stop enoxaparin 24 hours before the procedure and restart 24-72 hours after the procedure based on bleeding risk 2

Acute Coronary Syndromes

• For patients with STEMI requiring fibrinolysis who were previously on apixaban, administer enoxaparin as follows:
  • If age <75 years: 30 mg IV bolus, followed in 15 minutes by 1 mg/kg subcutaneously every 12 hours (maximum 100 mg for first 2 doses) 1
  • If age ≥75 years: no bolus, 0.75 mg/kg subcutaneously every 12 hours (maximum 75 mg for first 2 doses) 1

Common Pitfalls to Avoid

• Never administer unfractionated heparin to patients already receiving therapeutic subcutaneous enoxaparin 1
• Avoid switching between enoxaparin and unfractionated heparin due to increased bleeding risk 2
• Do not administer enoxaparin within 8-12 hours of neuraxial procedures (spinal/epidural anesthesia) 2, 3
• Failure to adjust dosing based on renal function can lead to drug accumulation and increased bleeding risk 1, 3

Monitoring Recommendations

• Regular clinical assessment for signs of bleeding or thrombosis 2
• For patients with renal impairment, obesity, or advanced age, consider monitoring anti-Xa levels, especially if treatment is prolonged 2
• Target anti-Xa level for therapeutic enoxaparin is 0.5-1.0 IU/mL when measured 4 hours after a dose 2

Remember that bridging anticoagulation with enoxaparin should be individualized based on the patient's thrombotic risk versus bleeding risk, with higher thrombotic risk patients generally requiring therapeutic anticoagulation during the apixaban interruption period 1, 2.