Initiating Heparin DVT Prophylaxis After Holding Apixaban
Yes, it is safe to initiate heparin for DVT prophylaxis 12 hours after holding Eliquis (apixaban). The pharmacodynamic effect of apixaban persists for approximately 24 hours after the last dose (about two drug half-lives), but prophylactic doses of heparin can be safely started after 12 hours 1.
Pharmacokinetic Considerations
- Apixaban has a terminal plasma half-life of 8-14 hours and reaches peak plasma concentration approximately 3 hours after oral administration 2
- The anticoagulant effect of apixaban can be expected to persist for at least 24 hours after the last dose 1
- When transitioning between anticoagulants, the timing is critical to prevent both excessive anticoagulation and periods of inadequate anticoagulation 2
Guidelines for Initiating DVT Prophylaxis After Apixaban
Timing Recommendations:
- For patients who have had apixaban held, prophylactic doses of heparin can be initiated after 12 hours from the last dose of apixaban 2
- This timing allows for sufficient clearance of apixaban to minimize the risk of excessive anticoagulation while providing necessary thromboprophylaxis 2
Dosing Options for DVT Prophylaxis:
- Unfractionated heparin: 5,000 units subcutaneously every 8 hours or every 12 hours 2, 3
- Enoxaparin: 40 mg subcutaneously once daily 2
- Dalteparin: 5,000 units subcutaneously once daily 2
Special Considerations
Patient-Specific Risk Factors:
- For patients with renal impairment: Consider using unfractionated heparin instead of LMWH, as LMWH is primarily cleared by the kidneys 2
- For patients at high risk of bleeding: Consider mechanical prophylaxis (sequential compression devices or foot pumps) until pharmacological prophylaxis is deemed safe 2, 4
Procedure-Related Considerations:
- If neuraxial anesthesia or epidural catheter is present, special timing considerations apply:
Clinical Evidence Supporting Safety
- Studies have shown that prophylactic doses of heparin can be safely initiated after holding direct oral anticoagulants like apixaban without significantly increasing bleeding risk 6
- The risk of DVT in hospitalized patients can be as high as 15% without prophylaxis, making timely initiation of thromboprophylaxis important 2
- In a study of patients with intracranial hemorrhage, starting chemical DVT prophylaxis within 24 hours post-procedure was not associated with increased risk of rebleeding 6
Common Pitfalls to Avoid
- Avoid bridging with therapeutic doses: Bridging with therapeutic doses of heparin or LMWH is not recommended when transitioning from apixaban to prophylactic anticoagulation 2
- Avoid measuring drug concentrations: There is no need to measure the concentration of apixaban before initiating prophylactic heparin 2
- Don't delay prophylaxis unnecessarily: Delaying DVT prophylaxis beyond 12 hours after holding apixaban may increase the risk of thrombotic events without providing additional safety benefits 6
By following these guidelines, you can safely initiate heparin DVT prophylaxis 12 hours after holding apixaban, balancing the risks of bleeding with the need for thromboprophylaxis.