What dose of oral Eliquis (apixaban) should a patient with pulmonary embolism (PE) receive when transitioning from a heparin drip, a loading dose or a maintenance dose?

From the Guidelines

For a patient with pulmonary embolism (PE) transitioning from a heparin drip to oral Eliquis (apixaban), a loading dose of 10 mg twice daily for the first 7 days is required, followed by a maintenance dose of 5 mg twice daily thereafter, as recommended by the most recent guidelines 1. When transitioning, discontinue the heparin infusion and start the first dose of Eliquis at the time the next heparin dose would have been due, or at the time of discontinuation of the continuous infusion. This overlap is not necessary as Eliquis has a rapid onset of action (1-3 hours) 1. Some key points to consider when transitioning to Eliquis include:

• Ensuring the patient has normal renal function before starting Eliquis, as dose adjustments may be needed for patients with severe renal impairment 1
• The loading dose is essential because it quickly achieves therapeutic anticoagulation levels in the blood, which is critical for treating an active thromboembolic event like PE
• Unlike warfarin, which requires 5-7 days to reach full anticoagulant effect, Eliquis works quickly but still benefits from an initial higher dose to rapidly achieve stable therapeutic levels
• The patient's bleeding risk should be assessed to identify and treat modifiable bleeding risk factors, and it may influence decision-making on the duration and regimen/dose of anticoagulant treatment 1

From the FDA Drug Label

Treatment of DVT and PE The recommended dose of apixaban tablets is 10 mg taken orally twice daily for the first 7 days of therapy. After 7 days, the recommended dose is 5 mg taken orally twice daily.

When transitioning a patient with Pulmonary Embolism (PE) from a heparin drip to oral Eliquis (apixaban), the patient should receive a loading dose of 10 mg twice daily for the first 7 days, followed by a maintenance dose of 5 mg twice daily 2.

• The initial dose is 10 mg twice daily for 7 days.
• The maintenance dose is 5 mg twice daily after the first 7 days.

From the Research

Transitioning from Heparin to Oral Eliquis

When transitioning a patient with pulmonary embolism (PE) from a heparin drip to oral Eliquis (apixaban), the dosing strategy is crucial for effective anticoagulation.

• The patient should start with a maintenance dose of Eliquis, as there is no need for a loading dose when transitioning from heparin to apixaban 3, 4.
• Apixaban has a rapid onset of action and predictable pharmacokinetics, allowing for a fixed-dose regimen without the need for initial parenteral anticoagulant therapy or laboratory monitoring 4.
• The fixed-dose regimen of oral apixaban is as effective as conventional treatment regimens and is associated with a clinically relevant reduction in major bleeding 4.

Considerations for Anticoagulation Therapy

• Anticoagulation is essential for patients with PE, and the choice of anticoagulant agent depends on various factors, including the patient's clinical probability of PE, hemodynamic stability, and risk of bleeding 5, 6.
• Non-vitamin K antagonist oral anticoagulants (NOACs), such as apixaban, are preferred over vitamin K antagonists (VKAs) due to their favorable safety profile and simplicity of use 5.
• The decision on the duration of anticoagulation should consider both the individual risk of PE recurrence and the individual risk of bleeding 5.