Should Eliquis (apixaban) and Plavix (clopidogrel) be continued or should Plavix (clopidogrel) and heparin be used?

Antithrombotic Management: Eliquis + Plavix vs. Plavix + Heparin

Continue Eliquis (apixaban) and Plavix (clopidogrel) together rather than switching to Plavix and heparin, as this combination provides superior protection against both thrombotic and embolic events without requiring the complexity and bleeding risks associated with heparin bridging. 1

Clinical Context Determines Optimal Strategy

The decision hinges on why the patient requires both anticoagulation and antiplatelet therapy:

For Atrial Fibrillation with Recent PCI/Stent

• Triple therapy (Eliquis + Plavix + aspirin) should be minimized to the shortest duration possible, typically discontinued at hospital discharge for most patients 1
• After discharge, continue dual therapy with Eliquis and Plavix (clopidogrel preferred over other P2Y12 inhibitors) for the appropriate duration based on presentation 1:
  • ACS presentation: Continue for 12 months 1
  • Stable ischemic heart disease: Continue for 6 months 1
• After completing the dual therapy period, continue Eliquis alone for stroke prevention 1

For Venous Thromboembolism with PCI

• The duration of anticoagulation must be reassessed first - if within the first 3 months of VTE treatment, anticoagulation takes priority 1
• For patients on indefinite anticoagulation who undergo PCI, continue Eliquis with Plavix rather than switching to heparin 1
• After 6 months of dual therapy, consider dose-reduced apixaban (2.5 mg twice daily) with continued Plavix if bleeding risk is acceptable 1

Why Heparin Bridging Should Be Avoided

• Bridging with heparin does NOT provide protection against coronary artery or stent thrombosis and significantly increases bleeding risk 2
• The ACC explicitly recommends against heparin bridging when managing DOACs like Eliquis in the perioperative setting 3
• For patients at low-to-moderate thrombotic risk, no bridging anticoagulation is recommended during temporary DOAC interruption 1, 4
• Heparin bridging is only considered for very high-risk patients (mechanical heart valves, recent VTE within 3 months, or recent stroke) requiring urgent procedures 1, 4

Dosing Considerations for Eliquis

• Standard dose: 5 mg orally twice daily 1
• Dose reduction to 2.5 mg twice daily if patient meets ≥2 of the following 1:
  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL
• For VTE secondary prevention after 6 months, either 5 mg or 2.5 mg twice daily can be considered 1

Critical Timing for Procedures

If a procedure is required while on this regimen:

• For low-bleeding-risk procedures: Continue both medications 1
• For moderate-to-high bleeding risk procedures 1, 3:
  • Hold Eliquis for 24 hours (skip 2 doses) if CrCl ≥50 mL/min 3
  • Hold Eliquis for 36 hours if CrCl 15-49 mL/min 3
  • Continue Plavix if within 12 months of drug-eluting stent or 6 weeks of bare-metal stent 1, 4
  • Resume Eliquis at least 6 hours post-procedure once hemostasis is secure 3

Common Pitfalls to Avoid

• Never discontinue dual antiplatelet therapy within 12 months of drug-eluting stent placement - the thrombotic risk far exceeds bleeding risk 1, 2
• Do not assume heparin provides equivalent protection to DOACs - it does not prevent stent thrombosis 2
• Avoid triple therapy (Eliquis + Plavix + aspirin) beyond hospital discharge in most patients due to 2-3 fold increase in bleeding complications 1
• Do not use vitamin K antagonists (warfarin) as an alternative - DOACs have superior bleeding profiles in VTE patients 1

Monitoring Requirements

• Assess bleeding risk using validated scores (e.g., PRECISE-DAPT score; high risk if ≥25) 1
• Evaluate renal function regularly as it affects both Eliquis dosing and elimination 1, 3
• Monitor for signs of bleeding (unusual bruising, prolonged bleeding from minor cuts, blood in urine/stool) 1
• Reassess the need for continued dual therapy at 6 and 12 months 1