From the Guidelines
When transitioning from low molecular weight heparin (LMWH) to apixaban for anticoagulation in a hospitalized patient, apixaban should be started immediately after discontinuing LMWH, or up to 2 hours before the next scheduled dose of LMWH would have been given. This recommendation is based on the American Society of Hematology 2020 guidelines for management of venous thromboembolism, which states that for patients treated with rivaroxaban or apixaban, there is no need for pretreatment with UFH or LMWH 1. The key considerations for this transition include:
- The rapid onset of action of apixaban, which reaches peak levels within 3-4 hours, allowing for a seamless transition from LMWH
- The importance of minimizing the risk of both thrombotic events from inadequate anticoagulation and bleeding complications from excessive anticoagulation
- The need for extra caution in patients with renal impairment (CrCl <30 mL/min), as LMWH clearance is delayed, potentially increasing bleeding risk during transition
- Ensuring the patient's platelet count and renal function are stable before making this switch, and considering any planned invasive procedures that might require temporary interruption of anticoagulation. It is also worth noting that other guidelines, such as the American College of Chest Physicians clinical practice guideline on perioperative management of antithrombotic therapy, suggest administering the last pre-operative LMWH bridging dose at approximately 24 hours over administering the last dose 10 to 12 hours before a surgery/procedure 1. However, these guidelines are more focused on the perioperative management of antithrombotic therapy, and the recommendation for immediate transition from LMWH to apixaban is based on the most relevant and recent guideline for the management of venous thromboembolism 1.
From the Research
Waiting Period for Restarting Apixaban after Stopping LMWH
- There is no specific guidance in the provided studies on the waiting period for restarting apixaban after stopping Low Molecular Weight Heparin (LMWH) for anticoagulation in a hospital inpatient.
- The studies primarily focus on the efficacy and safety of apixaban compared to LMWH or warfarin for the treatment of venous thromboembolism (VTE) in various patient populations 2, 3, 4.
- One study discusses the use of apixaban for the treatment of heparin-induced thrombocytopenia (HIT) and prevention of embolism in a patient with atrial fibrillation after multiple valve replacement, but does not address the waiting period for restarting apixaban after stopping LMWH 5.
- Another study compares the efficacy and safety of enoxaparin (a type of LMWH) with unfractionated heparin for the treatment of proximal lower limb deep-vein thrombosis, but does not provide information on the waiting period for restarting apixaban after stopping LMWH 6.