Can you bridge warfarin with Eliquis (apixaban) for pulmonary embolism (PE)?

Bridging Warfarin with Apixaban for Pulmonary Embolism

You do not need to bridge warfarin with apixaban for pulmonary embolism—apixaban can be started directly as monotherapy without any parenteral anticoagulation or warfarin overlap. 1

Direct Initiation of Apixaban

Apixaban is approved as a single-drug regimen for acute PE treatment, eliminating the need for any bridging therapy. The dosing strategy is:

• 10 mg twice daily for 7 days, followed by
• 5 mg twice daily for ongoing treatment 1, 2

This approach was validated in the AMPLIFY trial with 5,395 patients (1,836 with PE), demonstrating that apixaban monotherapy was non-inferior to conventional enoxaparin/warfarin therapy for preventing recurrent VTE (RR 0.84; 95% CI 0.60–1.18) 1

Safety Advantages Over Bridging

Major bleeding occurred significantly less frequently with apixaban compared to conventional bridging therapy (RR 0.31; 95% CI 0.17–0.55; P < 0.001), making the direct approach safer than traditional heparin-to-warfarin bridging 1

The composite outcome of major bleeding and clinically relevant non-major bleeding was 4.3% with apixaban versus 9.7% with conventional therapy (RR 0.44; 95% CI 0.36–0.55; P < 0.001) 1

Clinical Implications

If a patient is already on warfarin and you want to switch to apixaban, simply discontinue warfarin and start apixaban at the standard dosing regimen once the INR falls below therapeutic range. There is no need for overlapping heparin bridging during this transition 1, 3

Real-world data from 20,561 apixaban patients showed that direct apixaban initiation resulted in 27-39% lower major bleeding risk and 25-39% lower recurrent VTE risk compared to warfarin with parenteral anticoagulant bridging 4

Important Contraindications

Do not use apixaban in patients with:

• Severe renal impairment (creatinine clearance <30 mL/min) 5, 6
• Pregnancy or lactation 5, 3
• Antiphospholipid antibody syndrome (use warfarin instead) 5, 3

For cancer-associated PE, consider edoxaban or rivaroxaban as preferred alternatives, though apixaban remains an option with individualized assessment 5, 3

Practical Advantage

The single-drug approach with apixaban simplifies treatment and may reduce hospital length of stay compared to traditional heparin-to-warfarin bridging strategies 3, 7

Patients bridged from heparin to warfarin had 2.52 times longer hospital stays compared to those treated with direct-acting oral anticoagulants 7