Is it easier to transition back to Eliquis (apixaban) after Lovenox (enoxaparin)?

Transitioning from Lovenox (Enoxaparin) to Eliquis (Apixaban)

Yes, it is generally easier to transition back to Eliquis (apixaban) after Lovenox (enoxaparin) compared to other anticoagulation transitions, as no overlap period is required when switching from enoxaparin to apixaban. 1

Transition Protocol

• When transitioning from enoxaparin to apixaban, apixaban can be started at the time the next scheduled dose of enoxaparin would be due 1
• Unlike transitions to warfarin or some other DOACs (like dabigatran or edoxaban), no overlap period is required when switching from enoxaparin to apixaban 1
• For patients receiving enoxaparin, if the last dose was administered within the prior 8 hours, no additional enoxaparin should be given before starting apixaban 1
• If the last subcutaneous dose of enoxaparin was administered between 8 and 12 hours earlier, an additional dose of enoxaparin 0.3 mg/kg IV may be considered before transitioning to apixaban 1

Dosing Considerations

• For most indications, the standard apixaban dosing is 5 mg twice daily, though dose adjustments may be needed based on specific patient factors 1, 2
• For patients with at least two of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL, a reduced dose of 2.5 mg twice daily is recommended 2
• For initial VTE treatment, apixaban is typically started at 10 mg twice daily for 7 days, followed by 5 mg twice daily 1

Clinical Considerations and Precautions

• Patients with gastric or gastroesophageal tumors are at increased risk for hemorrhage with DOACs including apixaban; LMWH may be preferred in these patients 1
• For patients with renal impairment, apixaban may have advantages over other DOACs as it has lower renal clearance (only about 27% of total drug clearance) 1
• In patients with obesity class 2 or higher (BMI ≥35), monitoring of peak and/or trough levels may be considered when using apixaban 1
• For underweight patients (BMI <18.5), apixaban dose should be reduced to 2.5 mg twice daily if the patient also meets other criteria for dose reduction 1, 2

Monitoring After Transition

• Unlike warfarin, routine coagulation monitoring is not required for apixaban 1
• If bleeding occurs while on apixaban, the American College of Cardiology recommends temporarily discontinuing the medication and providing supportive care 3
• For major bleeding, consider reversal agents such as prothrombin complex concentrates or andexanet alfa 3
• Once bleeding is controlled and the patient is stable, apixaban can typically be resumed at least 6 hours after bleeding has been controlled 3

Comparative Efficacy and Safety

• Studies comparing apixaban to enoxaparin have shown similar efficacy in preventing venous thromboembolism 4, 5
• Some evidence suggests apixaban may have a better safety profile with lower rates of transfusions compared to enoxaparin 6, 5
• In a national database study of hip fracture surgery patients, those on Eliquis had significantly lower transfusion rates compared to those on Lovenox (OR 0.52, P = 0.005) 6

Remember that while the transition from enoxaparin to apixaban is relatively straightforward, the decision to switch should be based on the patient's specific clinical situation, indication for anticoagulation, and risk factors for bleeding or thrombosis.