What is the recommended protocol for transitioning a patient from heparin (Heparin Sodium) infusion to Eliquis (Apixaban) at home?

Transitioning from Heparin Infusion to Home Eliquis (Apixaban)

Stop the heparin infusion and start apixaban immediately without any overlap or bridging period—apixaban can be initiated as soon as the decision is made to transition to oral anticoagulation. 1

Direct Transition Protocol

Timing of Transition

• Discontinue heparin infusion at any time when the patient is clinically stable and ready for discharge 1
• Start apixaban immediately after stopping heparin—no waiting period is required 1
• No bridging or overlap is necessary between heparin and apixaban, as bridging increases bleeding risk without reducing thrombotic complications 1

Apixaban Dosing Regimen

• Initial loading phase: Apixaban 10 mg twice daily for the first 7 days 1
• Maintenance phase: Apixaban 5 mg twice daily starting on day 8 1
• Dose reduction to 2.5 mg twice daily if the patient meets 2 of 3 criteria: age >80 years, weight <60 kg, or serum creatinine >1.5 mg/dL 2

Key Clinical Considerations

Renal Function Assessment

• Check creatinine clearance before transition to ensure apixaban is appropriate 3
• Avoid apixaban if CrCl <30 mL/min—consider alternative anticoagulation in severe renal impairment 1
• No dose adjustment needed for CrCl >30 mL/min unless other dose reduction criteria are met 2

Contraindications to Direct Transition

• Active bleeding or high bleeding risk requiring continued parenteral anticoagulation monitoring 1
• Severe renal impairment (CrCl <30 mL/min) 1
• Conditions affecting oral absorption: bariatric surgery, short gut syndrome, or malabsorption 1
• Concurrent use of strong CYP3A4 inhibitors/inducers or P-glycoprotein modulators 1

Common Pitfalls to Avoid

Do NOT Bridge with Heparin

• Bridging anticoagulation is explicitly not recommended when transitioning to direct oral anticoagulants like apixaban 1
• Bridging increases bleeding risk by 2-3 fold without providing thrombotic benefit 1
• This represents a critical difference from warfarin transitions, where bridging was historically used 1

Do NOT Wait for Laboratory Monitoring

• No need to measure heparin levels or aPTT before starting apixaban 1
• No need to check anti-Xa levels for apixaban dosing 1
• Simply stop heparin and start apixaban per the dosing protocol above 1

Do NOT Delay Discharge

• Patients can be safely discharged home immediately after starting apixaban 1
• No inpatient observation period is required for the transition itself 1
• This contrasts with warfarin, which requires 5 days of heparin overlap and INR monitoring 1

Patient Education for Home Transition

Medication Adherence

• Emphasize twice-daily dosing (morning and evening, approximately 12 hours apart) 1
• Take with or without food—apixaban absorption is not significantly affected by meals 1
• Do not skip doses, as apixaban has a relatively short half-life of 12 hours 1

Bleeding Precautions

• Avoid NSAIDs (including ibuprofen, naproxen, ketorolac) due to increased bleeding risk 4
• Use acetaminophen for pain management as the preferred alternative 4
• Report any unusual bleeding (gums, nosebleeds, bruising, blood in urine/stool) immediately 1

Follow-up Planning

• Schedule outpatient follow-up within 1-2 weeks to assess adherence and any bleeding/thrombotic complications 1
• Renal function monitoring should occur at least annually, or more frequently if baseline CrCl is 30-50 mL/min 1