What is the comparison between Enoxaparin (Lovenox) and Apixaban (Eliquis) for Pulmonary Embolism (PE)?

From the Guidelines

For the treatment of pulmonary embolism (PE), Eliquis (apixaban) is preferred over Lovenox (enoxaparin) for most patients due to its convenience, oral administration, and comparable efficacy, as evidenced by the AMPLIFY trial 1. When considering the treatment of PE, several factors influence the choice between Lovenox and Eliquis.

• Lovenox is often used as initial therapy in the acute setting due to its immediate onset of action and is administered subcutaneously.
• Eliquis, with its oral formulation and fixed dosing, offers a more convenient option for long-term management without the need for monitoring, making it suitable for outpatient care. Key differences in their pharmacological profiles and patient-specific factors can guide the selection between these two medications.
• Eliquis directly inhibits factor Xa, while Lovenox indirectly inhibits factor Xa through antithrombin.
• The decision may also depend on patient characteristics such as renal function, pregnancy status, active cancer, or the risk of bleeding, where Lovenox might be preferred due to its reversibility and suitability in certain conditions. However, the most recent and highest quality evidence supports the use of Eliquis for its efficacy and safety profile in the treatment of PE, as demonstrated in the AMPLIFY trial 1, which showed that apixaban was noninferior to enoxaparin/warfarin in preventing recurrent VTE or VTE-related death and had a significantly lower incidence of major bleeding.

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). Efficacy and safety of apixaban for the treatment of DVT and PE, and for the reduction in the risk of recurrent DVT and PE following 6 to 12 months of anticoagulant treatment was derived from the AMPLIFY and AMPLIFY-EXT studies 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 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

Lovenox (enoxaparin) vs Eliquis (apixaban) for Pulmonary Embolism (PE):

• Apixaban was noninferior to enoxaparin/warfarin for the treatment of PE.
• The efficacy of apixaban was consistent across subgroups, including those with PE.
• Key points:
  • Apixaban was shown to be noninferior to enoxaparin/warfarin.
  • Efficacy in the initial treatment of VTE was consistent between the two subgroups (PE with or without DVT, and DVT without PE). 2

From the Research

Comparison of Lovenox and Eliquis for Pulmonary Embolism (PE)

• Lovenox (enoxaparin) is a low molecular weight heparin used to treat PE, while Eliquis (apixaban) is a direct oral anticoagulant (DOAC) that has been shown to be effective in treating PE 3, 4, 5.
• A study from 2003 compared enoxaparin monotherapy to conventional anticoagulation with intravenous unfractionated heparin and warfarin in patients with symptomatic PE, and found that enoxaparin was feasible and warranted further study 6.
• More recent studies have shown that DOACs like apixaban are noninferior to traditional anticoagulation therapy for treating PE, and have a lower risk of bleeding 3, 4, 5.
• Apixaban has been shown to be effective in reducing the risk of recurrent venous thromboembolism (VTE) without increasing the risk of major bleeding 4, 5.
• However, there is limited data on the use of enoxaparin in obese patients, and dosage adjustments may be necessary to achieve therapeutic anti-factor Xa levels 7.

Efficacy and Safety of Lovenox and Eliquis

• Enoxaparin has been shown to be effective in treating PE, but may require dosage adjustments in obese patients 6, 7.
• Apixaban has been shown to be effective in reducing the risk of recurrent VTE and has a lower risk of bleeding compared to traditional anticoagulation therapy 3, 4, 5.
• The choice between Lovenox and Eliquis for PE treatment should be based on individual patient factors, such as renal function, body weight, and bleeding risk 3, 4, 5.

Clinical Considerations

• Patients with PE should be assessed for their clinical probability of PE, and D-dimer testing and chest imaging should be used to confirm the diagnosis 3.
• The treatment of PE should be individualized based on patient factors, such as systolic blood pressure, renal function, and bleeding risk 3, 4, 5.
• Further research is needed to determine the optimal treatment strategies for PE in special populations, such as obese patients and those with cancer or renal dysfunction 4, 7.