Transitioning from Lovenox to Eliquis

Transition Protocol

When transitioning from enoxaparin to apixaban, apixaban can be started at the time the next scheduled dose of enoxaparin would be due, with no overlap period required, as recommended by the National Comprehensive Cancer Network 2, 3
For patients receiving enoxaparin, if the last dose was administered within the prior 8 hours, no additional enoxaparin should be given before starting apixaban, according to Circulation 5
If the last subcutaneous dose of enoxaparin was administered between 8 and 12 hours earlier, an additional dose of enoxaparin 0.3 mg/kg IV may be considered before transitioning to apixaban, as suggested by Circulation 5

For most indications, the standard apixaban dosing is 5 mg twice daily, though dose adjustments may be needed based on specific patient factors, as recommended by the National Comprehensive Cancer Network 1
For initial VTE treatment, apixaban is typically started at 10 mg twice daily for 7 days, followed by 5 mg twice daily, according to the National Comprehensive Cancer Network 1

Patients with gastric or gastroesophageal tumors are at increased risk for hemorrhage with DOACs including apixaban; LMWH may be preferred in these patients, as noted by the National Comprehensive Cancer Network 1, 2
For patients with renal impairment, apixaban may have advantages over other DOACs as it has lower renal clearance (only about 27% of total drug clearance), according to the National Comprehensive Cancer Network 3
In patients with obesity class 2 or higher (BMI ≥35), monitoring of peak and/or trough levels may be considered when using apixaban, as suggested by the European Heart Journal 6
For underweight patients (BMI <18.5), apixaban dose should be reduced to 2.5 mg twice daily if the patient also meets other criteria for dose reduction, according to the European Heart Journal 6

Unlike warfarin, routine coagulation monitoring is not required for apixaban, as stated by the National Comprehensive Cancer Network 3
If bleeding occurs while on apixaban, the American College of Cardiology recommends temporarily discontinuing the medication and providing supportive care, with a strength of evidence based on clinical guidelines 7
For major bleeding, consider reversal agents such as prothrombin complex concentrates or andexanet alfa, as recommended by the American College of Cardiology 7
Once bleeding is controlled and the patient is stable, apixaban can typically be resumed at least 6 hours after bleeding has been controlled, according to the American College of Cardiology 7