Can Eliquis (Apixaban) Be Used in HIT?
Yes, apixaban can be used in patients with heparin-induced thrombocytopenia (HIT), particularly in clinically stable patients without life-threatening thrombosis, though injectable anticoagulants remain preferred for acute or severe presentations. 1
Clinical Context and Guideline Support
The 2020 Anaesthesia guidelines explicitly recognize apixaban as a treatment option for HIT with a favorable benefit/risk ratio 1. When anticoagulation is needed in patients with a history of HIT, guidelines recommend prescribing oral anticoagulants (including DOACs like apixaban) or fondaparinux as first-line options, reserving argatroban, bivalirudin, and danaparoid only for situations where oral anticoagulants and fondaparinux are contraindicated 2.
Patient Selection Criteria
Apixaban is appropriate for:
- Clinically stable patients without severe renal or hepatic impairment 1
- Patients without life-threatening or limb-threatening thrombosis 1
- Patients at average bleeding risk 3
Injectable anticoagulants (argatroban or bivalirudin) should be used instead for:
- Severe HIT with massive pulmonary embolism, extensive thrombosis, arterial thrombosis, venous gangrene, or consumption coagulopathy 1
- Unstable patients requiring rapid titration and monitoring 1
Supporting Evidence
Apixaban does not affect PF4/heparin complex-platelet interactions, making it mechanistically safe in HIT 2, 4. Laboratory studies consistently demonstrate absence of platelet activation with apixaban in the presence of HIT antibodies (11% activation vs 82% with heparin, p<0.01) 4.
Clinical outcomes data:
- A prospective study of 30 patients with suspected HIT treated with apixaban showed platelet count normalization in all patients, zero new thromboses, and only 1 hemorrhagic event 5
- A retrospective review of 12 patients treated with DOACs for HIT (5 received apixaban) showed no new thrombosis during hospitalization and no subsequent thrombi at 6-month follow-up 3
- Case series demonstrate 0% thrombosis recurrence and 0% major bleeding in 21 patients treated with apixaban 1
Practical Implementation
Dosing: Standard dosing is 5 mg twice daily, adjusted for renal function, age, and weight as appropriate 6. For VTE treatment specifically, the recommended dose is 10 mg twice daily for 7 days, then 5 mg twice daily 3.
Transition strategy: Most patients (67-80%) receive argatroban initially before transitioning to apixaban once clinically stable 3, 7. This approach allows for immediate anticoagulation with a titratable agent while awaiting platelet recovery.
Timing: Apixaban can be started even while the patient remains thrombocytopenic, as demonstrated in case reports where patients were transitioned at platelet counts as low as 108 × 10⁹/L 8.
Comparison with Other Options
While rivaroxaban has slightly stronger prospective evidence (one study showing favorable platelet recovery in 9 of 10 patients) 2, apixaban's twice-daily dosing may offer more consistent anticoagulation 1. Both are considered acceptable alternatives 1.
Fondaparinux remains another option with no cross-reactivity with anti-PF4 antibodies, but requires subcutaneous injection and is contraindicated in severe renal failure 2.
Critical Pitfalls to Avoid
- Do not delay treatment: If HIT is suspected with high probability, start alternative anticoagulation immediately without waiting for laboratory confirmation 1
- Avoid warfarin in acute phase: Warfarin should not be started until platelet count recovers above 100 × 10⁹/L due to risk of venous limb gangrene or skin necrosis 1
- Assess severity appropriately: Do not use apixaban for unstable patients or those with severe thrombotic complications requiring intensive monitoring 1