What is the recommended protocol for switching from Lovenox (enoxaparin) to Eliquis (apixaban)?

How to Switch from Lovenox to Eliquis

Discontinue Lovenox (enoxaparin) and start Eliquis (apixaban) at the time of the next scheduled Lovenox dose—no bridging or overlap is needed. 1

Switching Protocol

The transition from Lovenox to Eliquis is straightforward and does not require complex timing or bridging anticoagulation:

• Stop Lovenox completely and begin Eliquis at the exact time when the next Lovenox injection would have been due 1
• No overlap period is necessary between the two medications 1
• No bridging anticoagulation with other agents is required during the transition 1

This approach differs from switching to warfarin, which requires overlap and INR monitoring. The direct oral anticoagulants like Eliquis have predictable pharmacokinetics that allow for immediate substitution 1.

Eliquis Dosing After Transition

The appropriate Eliquis dose depends on the indication for anticoagulation:

For Treatment of DVT/PE:

• Start with 10 mg twice daily for 7 days, then reduce to 5 mg twice daily 2, 1
• This higher initial dose is critical for acute VTE treatment 2

For Atrial Fibrillation:

• Standard dose: 5 mg twice daily 1
• Reduced dose: 2.5 mg twice daily if the patient has at least 2 of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 1

For Extended VTE Prevention (after initial treatment):

• 2.5 mg twice daily after completing at least 6 months of full-dose anticoagulation 2, 1

Special Considerations

Renal Function:

• Creatinine clearance 15-29 mL/min: Use with caution; dose adjustments may be needed based on indication 1
• Creatinine clearance <15 mL/min or dialysis: Eliquis is not recommended 1

Drug Interactions:

• Combined P-gp and strong CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir): Reduce Eliquis dose by 50% if taking 5 mg or 10 mg twice daily; avoid coadministration if already on 2.5 mg twice daily 1

Cancer-Associated Thrombosis:

• LMWH (Lovenox) remains preferred over DOACs for cancer-associated VTE, particularly in patients with gastric or gastroesophageal lesions 2
• Apixaban may be safer than rivaroxaban or edoxaban for patients with gastric/gastroesophageal lesions if a DOAC is chosen 2
• If switching from Lovenox to Eliquis in cancer patients, recognize this represents a deviation from preferred therapy 2

Common Pitfalls to Avoid

Do not overlap or bridge the medications—this increases bleeding risk without reducing thrombotic risk 2. The evidence from perioperative guidelines consistently shows that unnecessary bridging with parenteral anticoagulants increases bleeding complications 2.

Do not switch back and forth between Lovenox and Eliquis repeatedly, as medication changes can lead to dosing errors and increased bleeding risk 2.

Ensure the correct Eliquis dose for the indication—using the maintenance dose (5 mg twice daily) when the loading dose (10 mg twice daily) is needed for acute VTE can result in treatment failure 2, 1.

Verify renal function before switching, as severe renal impairment may make Eliquis inappropriate while Lovenox dosing can be adjusted 2, 1.