How long after discontinuing Heparin (unfractionated heparin) infusion should Eliquis (apixaban) be started?

Timing of Apixaban (Eliquis) Initiation After Discontinuing Heparin Infusion

Apixaban can be started immediately upon discontinuation of unfractionated heparin infusion without any waiting period. 1

Direct Oral Anticoagulant (DOAC) Transition Principles

The transition from parenteral anticoagulation to apixaban differs fundamentally from other DOACs:

• Apixaban does not require lead-in parenteral anticoagulation and can be initiated directly when transitioning from heparin infusion 1
• This contrasts with dabigatran and edoxaban, which require 5-10 days of UFH or LMWH pretreatment before switching 1
• Rivaroxaban similarly allows immediate transition without waiting periods 1

Practical Implementation

Start apixaban at the time you discontinue the heparin drip:

• Stop the heparin infusion 1
• Administer the first dose of apixaban (typically 10 mg twice daily for 7 days, then 5 mg twice daily for VTE treatment) at the same time or within hours 1
• No overlap period is necessary 1
• No bridging anticoagulation is required 1

Pharmacokinetic Rationale

The immediate transition is safe because:

• Apixaban has rapid onset of action (peak effect within 3-4 hours) 1
• Unfractionated heparin has a short half-life of approximately 60-90 minutes in patients with normal renal function 2
• The anticoagulant effect of heparin dissipates quickly after discontinuation, typically within 2-4 hours 2
• There is no clinically significant gap in anticoagulation when transitioning directly 1

Special Considerations

Renal impairment may affect timing:

• In patients with severe renal dysfunction, heparin elimination may be prolonged (half-life up to 118 minutes in nephrectomized patients) 2
• However, this does not typically require delaying apixaban initiation, as the overlap provides continuous anticoagulation 2
• Apixaban dosing itself may need adjustment in severe renal impairment (CrCl <25 mL/min), but timing of initiation remains unchanged 1

Common Pitfalls to Avoid

• Do not wait 24-48 hours as you would when discontinuing heparin before surgery or procedures 1
• Do not continue heparin overlap for days as required with warfarin (which needs minimum 5 days overlap) 1
• Do not confuse this with warfarin bridging protocols, where heparin must continue until INR is therapeutic for 24 hours 1
• Do not delay apixaban initiation thinking you need to "clear" the heparin first—this creates an unnecessary gap in anticoagulation and increases thrombotic risk 1