Transitioning from Eliquis to Lovenox
No, the patient should NOT take their usual dose of Eliquis on the morning they start enoxaparin. The Eliquis should be discontinued and enoxaparin should be started at the time of the next scheduled Eliquis dose. 1
Switching Protocol
When transitioning from apixaban (Eliquis) to enoxaparin (Lovenox), the FDA-approved prescribing information provides clear guidance:
- Discontinue Eliquis completely 1
- Begin enoxaparin at the usual time of the next scheduled Eliquis dose (typically 12 hours after the last dose for twice-daily regimens) 1
- Do not overlap or co-administer both medications 1
Rationale for Avoiding Overlap
The evidence strongly supports avoiding concurrent administration:
- Pharmacodynamic interaction: When apixaban and enoxaparin are given concomitantly, peak anti-factor Xa activity increases by 42% compared to apixaban alone, representing an additive effect that increases bleeding risk 2
- Mitigating excessive anticoagulation: Separating administration by transitioning at the next scheduled dose (12 hours) significantly reduces the pharmacodynamic interaction, with peak anti-Xa activity increasing by only 15% when enoxaparin is given 6 hours after apixaban 2
- No bridging required: Current perioperative guidelines explicitly state that bridging anticoagulation during the 24-48 hours after stopping DOACs is not generally required 3, 1
Clinical Context Considerations
The appropriateness of this transition depends on the clinical scenario:
- For elective procedures: Eliquis should be stopped 24-48 hours before the procedure (depending on bleeding risk), and enoxaparin would typically not be started until after the procedure for VTE prophylaxis 3, 1
- For therapeutic anticoagulation needs: The direct switch at the next scheduled dose maintains continuous anticoagulation without dangerous overlap 1
The key principle is that these two anticoagulants should never be taken together on the same morning. 1, 2