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 |