Can I start apixaban (eliquis) today in a patient with a deep vein thrombosis (DVT) who recently received a dose of Lovenox (enoxaparin), or should I wait until tomorrow?

Transitioning from Enoxaparin to Apixaban for DVT

You can start apixaban today without waiting until tomorrow, as apixaban does not require parenteral anticoagulation lead-in therapy for DVT treatment. 1, 2, 3

Immediate Initiation Protocol

Apixaban can be initiated directly without any parenteral anticoagulation for DVT treatment. 2 Unlike dabigatran and edoxaban, which require 5-10 days of parenteral lead-in therapy, apixaban and rivaroxaban have initiation dose regimens that allow immediate oral start. 1

Dosing Regimen

• Start apixaban 10 mg orally twice daily today (regardless of when the last enoxaparin dose was given) 1, 2, 3
• Continue this dose for the first 7 days 1, 2, 3
• Then transition to 5 mg orally twice daily starting on day 8 1, 2, 3
• Continue for at least 3 months minimum duration 2

Key Advantages of Apixaban

Apixaban was specifically designed with an initiation dose regimen (10 mg twice daily for 7 days) that eliminates the need for parenteral bridging. 1 This distinguishes it from dabigatran and edoxaban, which both require at least 5-10 days of parenteral anticoagulation before oral therapy can begin. 1

The AMPLIFY trial demonstrated that apixaban was noninferior to enoxaparin/warfarin for treatment of acute VTE, with significantly lower bleeding risk. 3, 4 Patients in this trial were allowed to enter with or without prior parenteral anticoagulation (up to 48 hours), confirming the safety of immediate transition. 3

Clinical Considerations

Timing of Last Enoxaparin Dose

• The single dose of enoxaparin already given provides some anticoagulation coverage 1
• No waiting period is required between the last enoxaparin dose and first apixaban dose 2, 3
• The apixaban initiation dose (10 mg twice daily) provides therapeutic anticoagulation from the start 3, 4

Special Populations Requiring Different Approach

If your patient has active cancer-associated DVT, reconsider this plan. The American College of Cardiology prefers enoxaparin 1 mg/kg subcutaneously every 12 hours or 1.5 mg/kg once daily for the first 6 months in cancer-associated thrombosis. 2 While some data suggests apixaban may be reasonable in cancer patients 5, LMWH remains the guideline-preferred agent. 1, 2

If severe renal impairment exists (CrCl <30 mL/min), continue enoxaparin instead. 2 Apixaban is contraindicated with CrCl <15 mL/min, and should be used with extreme caution between 15-30 mL/min. 2

Common Pitfalls to Avoid

• Do not confuse the VTE treatment dose (10 mg twice daily initially) with the atrial fibrillation dose (5 mg twice daily). 6 The higher initiation dose is critical for adequate anticoagulation in acute thrombosis. 1, 3
• Do not wait for the enoxaparin to "wear off" before starting apixaban. This creates a gap in anticoagulation and increases thrombosis risk. 2
• Do not use the reduced dose (2.5 mg twice daily) during initial treatment. This dose is only for extended secondary prevention after completing at least 6 months of standard therapy. 1, 2

Duration Planning

After the initial treatment phase, continue apixaban 5 mg twice daily for at least 3 months for provoked DVT. 2 For unprovoked DVT, consider indefinite anticoagulation with annual reassessment. 2 After 6 months of standard-dose therapy, you may consider reducing to 2.5 mg twice daily for extended secondary prevention to lower bleeding risk while maintaining efficacy. 1, 2