Can I restart Eliquis (apixaban) while Pradaxa (dabigatran) is unavailable?

Switching from Pradaxa to Eliquis

Yes, you can restart Eliquis (apixaban) when Pradaxa (dabigatran) is unavailable—simply start Eliquis at the time the next dose of Pradaxa would have been due. 1

Switching Protocol

The transition between DOACs is straightforward because both agents have short half-lives and predictable pharmacology. 1, 2

Timing of the Switch

• Start apixaban at the time of the next scheduled dabigatran dose 1
• No bridging anticoagulation is required when switching between DOACs 1
• No overlap period is necessary due to the rapid onset of action of apixaban (within 3-4 hours) 1

Key Considerations Before Switching

Verify that the patient does not have contraindications to apixaban, particularly:

• Severe renal impairment: Both dabigatran and apixaban require dose adjustment or avoidance in severe renal dysfunction, but dabigatran is more renally cleared (80%) compared to apixaban (27%) 3, 2
• Active bleeding or high bleeding risk: If the patient is switching due to bleeding on dabigatran, ensure hemostasis is achieved before restarting any anticoagulation 3
• Concurrent medications: Review for drug interactions, particularly CYP3A4 and P-glycoprotein inhibitors that can increase apixaban levels 3

Clinical Context for Switching

Reasons to Switch from Dabigatran to Apixaban

Apixaban demonstrates a superior bleeding profile compared to dabigatran in real-world evidence:

• Lower gastrointestinal bleeding risk: Apixaban is associated with significantly lower GI bleeding compared to dabigatran (HR 0.81,95% CI 0.70-0.94) 4
• Similar efficacy: No significant differences in ischemic stroke, systemic embolism, intracranial hemorrhage, or mortality between the two agents 4
• Twice-daily dosing: While both require twice-daily dosing, some patients may tolerate apixaban better due to its lower bleeding risk 4, 5

Special Populations

For elderly patients (≥80 years) or those with chronic kidney disease:

• Apixaban maintains its favorable bleeding profile in these high-risk populations 4
• The lower GI bleeding risk with apixaban versus dabigatran is consistent across age groups and renal function categories 4

Important Caveats

Do not switch if the patient is actively bleeding on dabigatran without first addressing the bleeding:

• Stop the current anticoagulant immediately 3, 6
• For life-threatening bleeding on dabigatran, idarucizumab is the specific reversal agent 3
• Determine if anticoagulation should be restarted based on thrombotic risk versus bleeding risk 3
• If restarting is appropriate, parenteral anticoagulation (unfractionated heparin) may be considered initially in high-risk situations before transitioning to oral therapy 3

Ensure the indication for anticoagulation is appropriate for either agent:

• Both dabigatran and apixaban are approved for nonvalvular atrial fibrillation and VTE treatment 3, 7
• Neither is appropriate for mechanical heart valves (warfarin only) 3
• For VTE, ensure the patient has completed any required initial parenteral anticoagulation phase if applicable 7