Converting From One Anticoagulant to Another

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One of the most common questions I have answered in the past year has been in regards to converting from one anticoagulant to another (especially with the release of the newer rivaroxaban, apixaban, and dabigatran). Perhaps the physician wants the patient to avoid multiple labs with warfarin monitoring with one of the newer agents while outpatient or maybe the patient cannot keep their Vitamin K rich food intake consistent with warfarin. Whatever the reason, these factor Xa inhibitors (apixaban, fondaparinux, and rivaroxaban) and direct thrombin inhibitor (dabigatran) are chipping into the warfarin market for different indications. 

CONVERTING APIXABAN (ELIQUIS)

 

warfarin to apixaban

stop warfarin and start apixaban when INR <2

apixaban to warfarin

start warfarin and stop apixaban 3 days later OR stop apixaban, begin a parenteral anticoagulant (UFH or LMWH) and warfarin at the time apixaban would have been due and stop LMWH or UFH when INR therapeutic

LMWH/fonda to apixaban

stop LMWH/fonda and start apixaban 0-2 hours before next dose LMWH/fonda due

heparin to apixaban

stop heparin and start apixaban same time

apixaban to LMWH/UFH

stop apixaban and start LMWH/UFH at the time apixaban would have been due

apixaban to oral anticoagulant other than warfarin

stop apixaban and begin the other at the time the next scheduled dose of apixaban would have been due

 

 

CONVERTING DABIGATRAN (PRADAXA)

 

warfarin to dabigatran

stop warfarin and start dabigatran when INR <2

dabigatran to warfarin

CrCl > 50 mL/min: start warfarin and stop dabigatran 3 days later

CrCl 31-50: start warfarin and stop dabigatran 2 days later

CrCl 15-30: start warfarin and stop dabigatran 1 day later

LMWH/fonda to dabigatran

Stop parenteral anticoagulant and administer dabigatran 0-2 hrs before next parenteral dose would have been given

IV heparin to dabigatran

Administer first dose of dabigatran at time of discontinuation of IV heparin infusion

dabigatran to LMWH/UFH

CrCl > 30 mL/min: start 12 hours after the last dose of dabigatran

CrCl < 30: start 24 hours after the last dose of dabigatran

dabigatran to oral anticoagulant other than warfarin

Stop dabigatran and begin the other anticoagulant at the time the next dose of dabigatran would have been due

*Dabigatran may alter INR results

 

 

CONVERTING RIVAROXABAN (XARELTO)

 

warfarin to rivaroxaban

Stop warfarin and start when INR < 2 (manufacturer says < 3 however, expert consensus recommends wait until INR ≤ 2.0 before starting a new oral anticoagulant.)

rivaroxaban to warfarin

Start warfarin and stop rivaroxaban 3 days later OR stop rivaroxaban, begin LMWH/UFH and warfarin at same time the next dose of rivaroxaban would have been given and stop LMWH/UFH when INR is acceptable

LMWH/fonda to rivaroxaban

Stop LMWH/fonda and start rivaroxaban 0-2 hours before the next dose of LMWH/fonda would have been given

IV heparin to rivaroxaban

Administer first dose of rivaroxaban at the same time as d/c heparin

rivaroxaban to LMWH/fonda

Stop rivaroxaban and administer at the time the next dose of rivaroxaban would have been given

rivaroxaban to oral anticoag other than warfarin

Stop rivaroxaban and begin the other anticoagulant at the time that the next scheduled dose of rivaroxaban would have been given

 

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