Timing of Apixaban Initiation After Stopping IV Heparin
You can start apixaban immediately (0-2 hours) after stopping intravenous heparin infusion.
Direct Transition Protocol
The most straightforward approach is to discontinue IV heparin and start apixaban within 0-2 hours without any waiting period. 1 The FDA-approved heparin labeling specifically addresses conversion to oral anticoagulants other than warfarin, stating that for patients on continuous IV heparin infusion, you should "stop intravenous infusion of heparin sodium immediately after administering the first dose of oral anticoagulant," or for intermittent IV heparin, "start oral anticoagulant 0 to 2 hours before the time that the next dose of heparin was to have been administered." 1
Key Pharmacologic Rationale
- Heparin has a very short half-life of approximately 60-90 minutes when given intravenously, so its anticoagulant effect dissipates rapidly after discontinuation 1
- Apixaban reaches therapeutic levels within 3-4 hours of oral administration, providing seamless anticoagulation coverage 2
- There is no need for bridging or overlap period when transitioning from IV heparin to direct oral anticoagulants like apixaban, unlike the transition to warfarin which requires 4-5 days of overlap 2
Clinical Context Considerations
Post-Procedural Setting
If transitioning after surgery or invasive procedures:
- Wait 24-72 hours post-procedure before starting therapeutic-dose apixaban depending on bleeding risk 2
- For major surgery with high bleeding risk: start apixaban at reduced dose (2.5 mg twice daily) at 48-72 hours, then increase to therapeutic dose (5 mg twice daily) 2
- For minor procedures with adequate hemostasis: start therapeutic-dose apixaban at 24 hours post-procedure 2
Active VTE Treatment
When treating acute venous thromboembolism:
- Transition directly from IV heparin to apixaban without delay once the decision is made to switch to oral therapy 1
- Apixaban dosing for acute VTE: 10 mg twice daily for 7 days, then 5 mg twice daily 2
Important Caveats
- Do not confuse this with warfarin transition, which requires several days of heparin overlap until INR is therapeutic 1, 3
- Ensure adequate renal function before starting apixaban; dose adjustment needed if creatinine clearance 15-50 mL/min or other risk factors present 2
- Verify hemostasis is adequate if transitioning in the post-operative period before initiating therapeutic anticoagulation 2
- Monitor for any active bleeding that would contraindicate immediate anticoagulation 1