Apixaban Dosing After Heparin Transition for Pulmonary Embolism
After 5 days of heparin infusion, the patient should complete only 2 additional days of apixaban 10 mg twice daily (for a total of 7 days from PE diagnosis, not 7 days from starting apixaban), then transition to 5 mg twice daily. 1, 2
Rationale for the 7-Day Total Duration
The critical distinction here is that the 7-day high-dose period is calculated from the time of PE diagnosis and initiation of anticoagulation, not from when apixaban is started. 1, 2
- The FDA-approved dosing regimen for apixaban in PE treatment specifies 10 mg twice daily for the first 7 days of therapy, followed by 5 mg twice daily. 2
- The European Society of Cardiology and American College of Chest Physicians both recommend this same 7-day initial treatment phase with the higher dose. 1
- Since your patient has already received 5 days of therapeutic anticoagulation with heparin, only 2 additional days of apixaban 10 mg twice daily are needed to complete the 7-day acute treatment phase. 1, 2
Key Advantage of Apixaban
- Unlike warfarin transitions, apixaban does not require overlapping parenteral anticoagulation—you can stop heparin and start apixaban immediately. 1
- The European Society of Cardiology specifically notes that no initial parenteral anticoagulation is required before starting apixaban, though in your case the patient has already received it. 1
After the Initial 7 Days
- Reduce to apixaban 5 mg twice daily and continue for at least 3 months total duration of anticoagulation. 1, 2
- For unprovoked PE or ongoing risk factors, extended anticoagulation beyond 3 months should be considered. 1
Common Pitfall to Avoid
Do not restart the full 7-day course of 10 mg twice daily when transitioning from heparin. 1 The European Heart Journal specifically warns against continuing the initial higher dose beyond 7 days from diagnosis, as this increases bleeding risk without additional benefit. 1 The 7-day period encompasses all therapeutic anticoagulation from the time of PE diagnosis, whether with heparin, apixaban, or a combination of both.