Does a patient on Eliquis (apixaban) 5mg twice daily (bid) for a pulmonary embolism (saddle embolus) require a heparin drip upon hospital admission?

From the Guidelines

For a patient on Eliquis (apixaban) 5 mg twice daily for a saddle pulmonary embolism from a year ago who gets admitted to the hospital, they typically do not need to be switched to a heparin drip. Eliquis should be continued during hospitalization in most cases, as it provides effective anticoagulation 1. Switching to heparin is generally unnecessary and may actually increase bleeding risk during the transition between anticoagulants. However, there are specific situations where changing to heparin might be necessary, such as if the patient needs emergency surgery, has developed severe kidney dysfunction, cannot take oral medications, or is experiencing breakthrough clotting despite Eliquis therapy. The decision should be individualized based on the reason for hospitalization and the patient's clinical status. Eliquis has predictable anticoagulant effects and doesn't require routine monitoring like heparin does, making it convenient to continue during hospitalization when possible. Some key points to consider when deciding whether to switch to heparin include:

• The patient's current clinical status and reason for hospitalization
• The presence of any contraindications to heparin therapy, such as active bleeding or severe thrombocytopenia
• The potential benefits and risks of switching to heparin, including the risk of bleeding or thrombosis during the transition period
• The availability of alternative anticoagulation options, such as low-molecular-weight heparin (LMWH) or fondaparinux, which may be preferred in certain situations 1. Unnecessary switching between anticoagulants can create periods of under or over-anticoagulation, potentially increasing risk of clotting or bleeding.

From the FDA Drug Label

1. 5 Acute PE in Hemodynamically Unstable Patients or Patients who Require Thrombolysis or Pulmonary Embolectomy Initiation of apixaban tablets are not recommended as an alternative to unfractionated heparin for the initial treatment of patients with PE who present with hemodynamic instability or who may receive thrombolysis or pulmonary embolectomy.

The patient is on apixaban 5 mg bid for a saddle embolus from a year ago. If they get admitted to the hospital, the FDA label does not directly address the need for a heparin drip in this specific scenario. However, it does state that unfractionated heparin is recommended for the initial treatment of patients with PE who present with hemodynamic instability or who may receive thrombolysis or pulmonary embolectomy 2. Since the patient's current condition is not specified, it is unclear if they require a heparin drip. As a conservative clinical decision, it would be prudent to consider the patient's current clinical status and consult with a healthcare professional to determine the best course of action.

From the Research

Anticoagulation Therapy for Saddle Embolus

• The patient is currently on Eliquis (apixaban) 5mg twice a day for a saddle embolus that occurred a year ago.
• The question is whether the patient needs to be on a heparin drip if they are admitted to the hospital.

Current Anticoagulation Regimen

• The patient is already on a direct oral anticoagulant (DOAC), which is a first-line agent for treating venous thromboembolism and preventing stroke in patients with nonvalvular atrial fibrillation 3.
• The use of DOACs, such as apixaban, has been shown to be effective in preventing recurrent thromboembolism with a lower risk of bleeding compared to traditional anticoagulants like heparin and warfarin 4.

Need for Heparin Drip

• There is no clear indication that the patient needs to be switched to a heparin drip, as the current anticoagulation regimen with apixaban is effective and has a lower risk of bleeding 4.
• The American Society of Hematology guidelines recommend individualized assessment of risk of thrombosis and bleeding, and the use of heparin may be preferred in certain situations, but it is not necessarily required for patients already on a DOAC 5.
• The patient's current anticoagulation regimen should be continued, and the need for a heparin drip should be assessed on a case-by-case basis, taking into account the patient's individual risk factors and medical history 6, 7.