What is the recommended dosing for transitioning from Eliquis (apixaban) 2.5mg to Lovenox (enoxaparin)?

Transitioning from Eliquis 2.5mg to Lovenox

Stop apixaban 2.5mg twice daily and start enoxaparin 1 mg/kg subcutaneously every 12 hours at the time of the next scheduled apixaban dose, without any bridging or overlap period.

Dosing Algorithm for Enoxaparin

The appropriate enoxaparin dosing depends on your clinical indication:

For VTE Treatment (Cancer-Associated or Standard)

• Standard dosing: Enoxaparin 1 mg/kg subcutaneously every 12 hours (for BMI <40 kg/m²) 1
• Obesity adjustment: 0.8 mg/kg subcutaneously every 12 hours if BMI ≥40 kg/m² 1
• Alternative regimen: 1.5 mg/kg once daily can be considered after the first month 1

For Atrial Fibrillation (Perioperative Bridging)

• Therapeutic dosing: 1 mg/kg subcutaneously every 12 hours 1
• This maintains full anticoagulation during the transition period

Renal Dosing Adjustments

• CrCl <30 mL/min: Reduce to 1 mg/kg subcutaneously every 24 hours 1
• Monitor anti-Xa levels if available in patients with severe renal impairment

Timing Considerations

The transition is straightforward because apixaban has a short half-life of approximately 12 hours 1. Unlike warfarin or when transitioning to edoxaban/dabigatran, concurrent administration with parenteral anticoagulants is not required 1.

Practical Steps:

1. Administer the last dose of apixaban 2.5mg as scheduled
2. Start enoxaparin at the time the next apixaban dose would have been due (12 hours later)
3. No overlap or gap in anticoagulation is necessary

Important Clinical Caveats

Apixaban 2.5mg twice daily is a reduced dose, typically used for:

• Atrial fibrillation stroke prevention in patients meeting dose-reduction criteria (≥2 of: age ≥80 years, weight ≤60 kg, serum creatinine ≥1.5 mg/dL) 1
• Extended VTE prophylaxis after initial 6 months of treatment 1

Verify the indication for anticoagulation to ensure appropriate enoxaparin dosing. If the patient was on apixaban 2.5mg for VTE treatment (not extended prophylaxis), full therapeutic enoxaparin dosing (1 mg/kg every 12 hours) is required 1.

Common Pitfalls to Avoid

• Do not overlap medications: Unlike warfarin transitions, DOACs and LMWH should not be given concurrently 1
• Do not underdose enoxaparin: If transitioning for active VTE treatment, use full therapeutic dosing (1 mg/kg every 12 hours), not prophylactic dosing 1
• Monitor for drug interactions: If the patient was on apixaban 2.5mg due to P-glycoprotein/CYP3A4 inhibitors, these interactions do not affect enoxaparin 1
• Assess renal function: Enoxaparin requires dose adjustment for CrCl <30 mL/min, whereas apixaban 2.5mg may have been used for moderate renal impairment 1