What is the comparison between Enoxaparin (Lovenox) and Apixaban (Eliquis)?

From the Guidelines

Eliquis (apixaban) is the preferred choice over Lovenox (enoxaparin) for the treatment of venous thromboembolic disease due to its equivalent efficacy and lower bleeding risk, as demonstrated in recent clinical trials 1. When considering the treatment of venous thromboembolic disease, several factors come into play, including the patient's kidney function, the need for rapid anticoagulation, and the convenience of administration.

• Lovenox (enoxaparin) is a low molecular weight heparin that is given by subcutaneous injection, typically dosed at 1 mg/kg twice daily or 1.5 mg/kg once daily for treatment purposes.
• Eliquis (apixaban) is an oral direct factor Xa inhibitor taken twice daily, typically at a dose of 5 mg twice daily for treatment, making it more convenient for long-term outpatient use. The choice between these medications depends on the specific clinical situation, patient preferences regarding administration route, and kidney function.
• According to the NCCN clinical practice guidelines in oncology, apixaban is assigned a category 1 recommendation for the treatment of DVT/PE, indicating that it is a preferred treatment option 1.
• A study published in the Journal of the National Comprehensive Cancer Network found that apixaban had similar efficacy to prevent VTE recurrence and reduce major bleeding events compared with enoxaparin and vitamin K antagonist 1. Overall, the use of Eliquis (apixaban) is recommended over Lovenox (enoxaparin) due to its equivalent efficacy, lower bleeding risk, and convenience of administration, as supported by recent clinical trials and guidelines 1.

From the FDA Drug Label

The efficacy profile of apixaban was generally consistent across subgroups of interest for this indication (e.g., age, gender, race, body weight, renal impairment). Apixaban was shown to be noninferior to enoxaparin/warfarin in the AMPLIFY study for the primary endpoint of recurrent symptomatic VTE (nonfatal DVT or nonfatal PE) or VTE-related death over 6 months of therapy. In the AMPLIFY study, patients were stratified according to their index event of PE (with or without DVT) or DVT (without PE). Efficacy in the initial treatment of VTE was consistent between the two subgroups Adverse reactions related to bleeding occurred in 417 (15.6%) apixaban-treated patients compared to 661 (24.6%) enoxaparin/warfarin-treated patients.

Lovenox (Enoxaparin) vs Eliquis (Apixaban):

• Efficacy: Apixaban was noninferior to enoxaparin/warfarin in the treatment of DVT and PE.
• Bleeding Risk: Apixaban had a lower bleeding risk compared to enoxaparin/warfarin, with a relative risk of 0.31 for major bleeding.
• Key differences: Apixaban is an oral anticoagulant, while enoxaparin is a subcutaneous anticoagulant. Apixaban has a more predictable pharmacokinetic profile and does not require regular monitoring of INR levels, unlike warfarin. 2 2

From the Research

Lovenox vs Eliquis: Comparison of Anticoagulants

• Lovenox (enoxaparin) is a low-molecular-weight heparin, while Eliquis (apixaban) is a direct oral anticoagulant.
• The choice between Lovenox and Eliquis depends on the patient's specific condition, such as nonvalvular atrial fibrillation, deep vein thrombosis, or pulmonary embolism 3.
• For patients with nonvalvular atrial fibrillation, apixaban, dabigatran, rivaroxaban, or warfarin can be considered for the prevention of stroke and systemic embolism 3.

Efficacy and Safety

• A study comparing rivaroxaban and warfarin in patients with unusual site deep vein thrombosis found that rivaroxaban had comparable efficacy and a lower risk of bleeding complications and major bleeding 4.
• Another study found that enoxaparin was associated with a higher risk of major bleeding compared to nadroparin, especially with twice-daily dosing 5.
• Protamine can be used to reverse bleeding associated with low-molecular-weight heparins like enoxaparin, but its effectiveness is limited and it only partially reverses anti-Xa activity 6.

Clinical Considerations

• The risks of bleeding and thrombosis should be considered when deciding on anticoagulation therapy 3.
• Hospitalized patients at high risk of thrombosis should receive prophylaxis with low-molecular-weight heparin, low-dose unfractionated heparin, or fondaparinux 3.
• Patients presenting with acute coronary syndrome should receive intravenous unfractionated heparin or enoxaparin at hospital admission 3.
• The choice of anticoagulant should be individualized based on the patient's specific condition, renal function, and other factors 4, 7, 5.