Can Eliquis (apixaban) be switched to Lovenox (enoxaparin) in patients placed on Nothing Per Oral (NPO) status?

Switching from Eliquis (Apixaban) to Lovenox (Enoxaparin) for NPO Patients

Yes, you can switch from Eliquis (apixaban) to Lovenox (enoxaparin) when a patient is placed on NPO status, as parenteral anticoagulation is recommended for patients who cannot take oral medications. 1

Rationale for Switching to Parenteral Anticoagulation

• When patients are placed on NPO status, oral medications including direct oral anticoagulants (DOACs) like apixaban cannot be administered, necessitating alternative routes of anticoagulation 1
• Guidelines specifically recommend considering parenteral anticoagulation (such as enoxaparin) for patients who are NPO or awaiting invasive procedures 1
• Oral medications should not be administered until a swallowing screen using a validated tool has been completed and found normal; alternative routes such as intravenous and rectal administration should be considered while a patient is NPO 1

Protocol for Switching from Apixaban to Enoxaparin

1. Timing of Last Apixaban Dose:

   • Consider the half-life of apixaban (approximately 12 hours) when planning the transition 1
   • For patients with normal renal function, enoxaparin can be started 12-24 hours after the last dose of apixaban 1

2. Enoxaparin Dosing:

   • For younger patients <75 years: 1 mg/kg SC every 12 hours 1
   • For patients ≥75 years: 0.75 mg/kg SC every 12 hours without an initial IV bolus 1
   • For patients with impaired renal function (creatinine clearance <30 mL/min): 1 mg/kg SC once daily or consider unfractionated heparin instead 1

3. Special Considerations:

   • Patients initially treated with apixaban should not be abruptly switched to heparin and vice versa because of increased risk of bleeding 1
   • For patients with high thrombotic risk, ensure minimal gap in anticoagulation coverage during the transition 1

When to Switch Back to Apixaban

• Resume apixaban once the patient is no longer NPO and can safely swallow medications 1
• No need for overlap between enoxaparin and apixaban when transitioning back 1
• Consider a swallowing assessment before restarting oral medications to ensure patient safety 1

Monitoring During Transition

• Monitor for signs of bleeding during the transition period 1
• For patients with renal impairment, closer monitoring may be necessary as both drugs are affected by kidney function 1
• Consider patient-specific factors such as weight, age, and comorbidities when determining appropriate dosing 1

Potential Pitfalls and Caveats

• Avoid switching between different anticoagulants unnecessarily as this may increase bleeding risk 1
• Be aware that enoxaparin requires dose adjustment in renal impairment, which is different from apixaban dose adjustments 1
• For patients with high bleeding risk, consider the risk-benefit ratio of full anticoagulation versus prophylactic dosing during the NPO period 1
• In patients undergoing procedures, timing of enoxaparin administration is critical for neuraxial anesthesia safety (avoid within 24 hours before spinal/epidural placement) 1

This approach ensures continuous anticoagulation coverage while maintaining patient safety during periods when oral medication administration is not possible.