What is the recommended timing for transitioning from heparin to Eliquis (apixaban)?

Timing for Transitioning from Heparin to Apixaban (Eliquis)

For patients transitioning from heparin to apixaban (Eliquis), apixaban should be started immediately when the next dose of heparin would be due, with no need for overlapping therapy. 1

General Principles for Heparin to Apixaban Transition

• Unlike warfarin, which requires 5-10 days of overlapping therapy with heparin, direct oral anticoagulants (DOACs) like apixaban have a rapid onset of action and do not require extended overlap periods 1
• Apixaban and rivaroxaban do not require pretreatment with heparin, unlike dabigatran and edoxaban which need 5-10 days of heparin before switching 1
• Apixaban achieves therapeutic anticoagulation rapidly, with peak effect within 3-4 hours of administration 1

Specific Transition Protocol

For Intravenous Unfractionated Heparin (UFH):

• Discontinue the heparin infusion
• Start apixaban immediately when the next dose of heparin would have been due 1
• No need for overlapping therapy due to the short half-life of UFH (approximately 1-2 hours) 2

For Low Molecular Weight Heparin (LMWH):

• Administer the first dose of apixaban at the time the next scheduled dose of LMWH would be due 1
• No need for overlapping therapy 1

Dosing Considerations

• For venous thromboembolism (VTE) treatment, apixaban should be started at 10 mg twice daily for 7 days, followed by 5 mg twice daily 1
• For atrial fibrillation, standard dosing is 5 mg twice daily (or 2.5 mg twice daily in patients meeting dose reduction criteria) 1

Special Considerations

Renal Function:

• Unlike dabigatran which requires dose adjustments based on renal function, apixaban has less renal clearance (25%) and generally doesn't require adjustment solely for mild to moderate renal impairment 1
• Monitor renal function before transition as it may affect the timing of discontinuation of heparin 1

High Bleeding Risk Procedures:

• If a patient is being transitioned for an upcoming procedure with high bleeding risk, apixaban should be discontinued 2-3 days before the procedure 1
• For patients with normal renal function, holding apixaban for 24-48 hours is generally sufficient 1

Early Phase of VTE Treatment:

• For patients in the early phase of VTE treatment, the transition should be carefully managed with the higher initial dose of apixaban (10 mg twice daily for 7 days) 1
• A personalized approach may be needed for patients with extensive thrombosis 1

Common Pitfalls to Avoid

• Avoid unnecessary bridging: Unlike warfarin, apixaban does not require bridging with parenteral anticoagulants 1
• Avoid overlapping therapy: Simultaneous administration of heparin and apixaban increases bleeding risk without additional antithrombotic benefit 1
• Avoid delaying transition: Prompt transition to apixaban when appropriate reduces hospitalization time and costs 1
• Avoid incorrect dosing: Ensure the correct initial dosing regimen is used based on the indication (VTE vs. atrial fibrillation) 1

By following these guidelines, the transition from heparin to apixaban can be accomplished safely and effectively, minimizing both thrombotic and bleeding risks.