Transitioning from Heparin to Apixaban (Eliquis)
When transitioning from heparin to apixaban, stop heparin infusion and immediately start apixaban at the appropriate dose based on the patient's renal function, with no overlap period required.
Protocol for Normal Renal Function
- For patients with normal renal function (CrCl >50 mL/min), discontinue heparin infusion and immediately start apixaban at the standard dose 1
- No bridging period is required between heparin and apixaban due to apixaban's rapid onset of action 2
- Standard dosing for apixaban is 5 mg twice daily for most indications, or 2.5 mg twice daily for specific populations (age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL) 2
- Monitor patient for signs of bleeding during the first 24 hours after transition 1
Protocol for Impaired Renal Function
- For patients with moderate renal impairment (CrCl 30-50 mL/min), discontinue heparin and start apixaban at the appropriate dose based on indication and patient characteristics 2
- For patients with severe renal impairment (CrCl 15-29 mL/min), use apixaban with caution as systemic exposure may be increased by 36% compared to patients with normal renal function 2
- No dose adjustment is specifically recommended for renal impairment alone, but consider dose reduction to 2.5 mg twice daily if the patient meets other criteria (age ≥80 years, body weight ≤60 kg) 2
- Apixaban is not recommended for patients with CrCl <15 mL/min or on dialysis due to limited clinical data 2
Special Considerations
- Unlike transitioning from heparin to warfarin, which requires 5 days of overlap, apixaban can be started immediately after stopping heparin 1, 3
- For patients with heparin-induced thrombocytopenia (HIT), apixaban may be considered as an alternative to traditional non-heparin anticoagulants, though argatroban is the preferred agent in this scenario 1, 4
- For patients requiring invasive procedures, apixaban should be discontinued 3 days before high bleeding risk procedures and 2 days before low bleeding risk procedures if CrCl >30 mL/min 5
- For patients with CrCl between 15-30 mL/min requiring procedures, discontinue apixaban 4 days before high bleeding risk procedures 5
Monitoring Requirements
- No routine coagulation monitoring is required when transitioning from heparin to apixaban 2
- Unlike heparin, which requires aPTT monitoring, or warfarin, which requires INR monitoring, apixaban has predictable pharmacokinetics that do not require laboratory monitoring 2, 6
- Monitor for signs of bleeding, particularly in patients with risk factors such as concomitant use of drugs affecting hemostasis, older age, or renal impairment 2
Common Pitfalls to Avoid
- Avoid overlapping heparin and apixaban therapy as this increases bleeding risk without providing additional antithrombotic benefit 3
- Avoid dose reduction based solely on mild renal impairment; dose adjustments are only recommended when multiple criteria are met 2
- Do not administer loading doses of apixaban when transitioning from heparin 2
- For patients previously on heparin who developed HIT, ensure platelet count has stabilized before initiating apixaban 4
- Avoid concomitant use of strong dual inhibitors of CYP3A4 and P-glycoprotein (P-gp) as they can significantly increase apixaban exposure 2