When to discontinue heparin after initiating apixaban?

From the Guidelines

Discontinuation of heparin after initiating apixaban should occur immediately, as there is no need for pretreatment with heparin when using apixaban.

Key Considerations

• When initiating apixaban, no overlap with heparin is required 1
• Apixaban can be started at a higher dose for the first week of therapy, eliminating the need for heparin pretreatment 1
• This approach is specific to apixaban and rivaroxaban, as other direct oral anticoagulants (DOACs) like dabigatran and edoxaban require pretreatment with heparin for up to 5 to 10 days 1
• The decision to discontinue heparin is based on the guidelines for management of venous thromboembolism provided by the American Society of Hematology in 2020 1

From the Research

Discontinuation of Heparin after Initiating Apixaban

• The decision to discontinue heparin after initiating apixaban depends on various factors, including the patient's condition, renal function, and anti-Xa levels 2, 3.
• A study published in 2019 found that monitoring apixaban anti-Xa levels can help guide the transition from apixaban to heparin in patients with acute kidney injury 2.
• Another study published in 2020 found that the initial anti-factor Xa measurement is not predictive of the duration of direct oral anticoagulant influence in patients transitioning to heparin, but the presence of interacting medications can increase the duration of influence 3.
• In terms of specific timing, one case report found that heparin can be safely discontinued when apixaban anti-Xa levels are less than 50 ng/mL, which was achieved approximately 36 hours after the last apixaban dose 2.
• However, another study found that the median duration of influence of apixaban on heparin antifactor Xa levels was 62.7 hours, suggesting that heparin may need to be continued for a longer period than currently stated in the literature 3.

Factors to Consider

• Renal function: Patients with acute kidney injury may require closer monitoring of anti-Xa levels and heparin dosing 2, 4.
• Interacting medications: The presence of interacting medications can increase the duration of influence of apixaban on heparin antifactor Xa levels 3.
• Anti-Xa levels: Monitoring anti-Xa levels can help guide the transition from apixaban to heparin and ensure that heparin is discontinued safely 2, 3.

Clinical Implications

• The discontinuation of heparin after initiating apixaban should be individualized based on patient-specific factors, including renal function, interacting medications, and anti-Xa levels 2, 3.
• Close monitoring of anti-Xa levels and heparin dosing is necessary to ensure safe and effective anticoagulation therapy 2, 3.