What is the recommended dosing when switching from Lovenox (enoxaparin) to Eliquis (apixaban)?

Switching from Lovenox (Enoxaparin) to Eliquis (Apixaban)

When switching from Lovenox (enoxaparin) to Eliquis (apixaban) for venous thromboembolism treatment, discontinue enoxaparin and begin apixaban at the usual time of the next scheduled dose of enoxaparin, starting with 10 mg twice daily for 7 days followed by 5 mg twice daily. 1

Dosing Protocol

Initial Apixaban Dosing

• For VTE treatment, apixaban should be initiated at 10 mg orally twice daily for the first 7 days, followed by 5 mg orally twice daily 2, 1
• No overlap period is required when transitioning from enoxaparin to apixaban - simply start apixaban at the time the next enoxaparin dose would have been due 1
• Unlike transitioning to warfarin, no bridging therapy is needed when switching from enoxaparin to apixaban 2

Maintenance Dosing

• After the initial 7-day treatment period with 10 mg twice daily, continue with 5 mg twice daily for at least 3 months 2, 1
• For extended treatment beyond 6 months, either continue with 5 mg twice daily or consider reducing to 2.5 mg twice daily 2, 3

Dose Adjustments for Special Populations

Renal Impairment

• No dose adjustment is required for patients with mild to moderate renal impairment 1
• Use with caution in patients with severe renal impairment (CrCl <30 mL/min) as these patients were excluded from clinical trials 3
• Unlike enoxaparin, which requires dose adjustment to 1 mg/kg once daily in patients with CrCl <30 mL/min, apixaban does not have specific dose adjustments for renal impairment in VTE treatment 2, 1

Elderly and Low Body Weight

• Consider dose reduction to 2.5 mg twice daily if the patient meets at least 2 of the following 3 criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 3

Important Considerations

Timing of Transition

• The transition should be timed to coincide with the next scheduled dose of enoxaparin 1
• For patients on twice-daily enoxaparin (1 mg/kg every 12 hours), take the first dose of apixaban when the next enoxaparin dose would have been due 1
• For patients on once-daily enoxaparin (1.5 mg/kg daily), take the first dose of apixaban when the next enoxaparin dose would have been due 1

Monitoring

• Unlike enoxaparin, routine laboratory monitoring of anticoagulant effect is not required for apixaban 1
• Consider monitoring anti-Xa levels in high-risk patients with potential drug interactions, particularly those taking strong dual inhibitors of CYP3A4 and P-glycoprotein 4

Common Pitfalls to Avoid

• Do not overlap enoxaparin and apixaban therapy as this increases bleeding risk 1
• Do not confuse VTE treatment dosing (10 mg BID for 7 days, then 5 mg BID) with atrial fibrillation dosing (5 mg BID) 3
• Avoid abrupt discontinuation of anticoagulation without an alternative anticoagulant due to increased thrombotic risk 1
• Be aware of potential drug interactions, particularly with strong dual inhibitors of CYP3A4 and P-glycoprotein, which may increase apixaban levels 4

Clinical Evidence Supporting Transition

• Apixaban has demonstrated efficacy in VTE treatment comparable to traditional anticoagulation regimens 2
• In clinical trials, apixaban showed a favorable bleeding profile compared to enoxaparin for thromboprophylaxis 5
• The ADVANCE-2 trial demonstrated that apixaban was more effective than enoxaparin for VTE prevention after orthopedic surgery without increased bleeding risk 5

By following this protocol for transitioning from Lovenox to Eliquis, you can ensure effective anticoagulation while minimizing the risk of thrombotic events or bleeding complications.