Switching from various anticoagulants

CONVERTING APIXABAN (ELIQUIS)

 
Warfarin to Stop warfarin and start apixaban when INR <2.
apixaban
Apixaban to Start warfarin and stop apixaban 3 days later, or stop
warfarin apixaban, begin a parenteral anticoagulant (UFH or
LMWH) and warfarin at the time apixaban would
have been due, and then stop LMWH or UFH when
INR therapeutic.
LMWH/fonda Stop LMWH/fonda and start apixaban 0-2 hours
to apixaban before next LMWH/fonda dose is due.
Heparin to Stop heparin and start apixaban at the same time.
apixaban
Apixaban to Stop apixaban and start LMWH/UFH at the time
LMWH/UFH when apixaban would have been due.
Apixaban to Stop apixaban and begin the other agent at the time
oral when the next scheduled dose of apixaban would
anticoagulant have been due.
other than
warfarin
 
 
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 mL/min: Start warfarin and stop
dabigatran 2 days later
CrCl 15-30 mL/min: Start warfarin and stop
dabigatran 1 day later
LMWH/fonda to Stop parenteral anticoagulant and administer
dabigatran dabigatran 0-2 hrs before the next parenteral
dose would have been administered.
IV heparin to Administer first dose of dabigatran at the
dabigatran time of discontinuation of IV heparin
infusion.
Dabigatran to CrCl >30 mL/min: Start 12 hours after the last
LMWH/UFH dose of dabigatran
CrCl <30 mL/min: Start 24 hours after the last
dose of dabigatran
Dabigatran to oral Stop dabigatran and begin the other
anticoagulant other anticoagulant at the time when the next dose
than warfarin of dabigatran would have been due.
*Dabigatran may alter INR results
 
 
CONVERTING RIVAROXABAN (XARELTO)
 
Warfarin to Stop warfarin and start when INR <2. However, the
rivaroxaban manufacturer advises when INR <3.
Rivaroxaban Start warfarin and stop rivaroxaban 3 days later, or stop
to warfarin rivaroxaban, begin LMWH/UFH and warfarin at same
time when the next dose of rivaroxaban would have
been given, and then stop LMWH/UFH when INR is
acceptable.
LMWH/fond Stop LMWH/fonda and start rivaroxaban 0-2 hours
a to before the next dose of LMWH/fonda would have been
rivaroxaban given.
IV heparin to Administer first dose of rivaroxaban at the same time as
rivaroxaban d/c heparin.
Rivaroxaban Stop rivaroxaban and administer at the time when the
to next dose of rivaroxaban would have been given.
LMWH/fond
a
Rivaroxaban Stop rivaroxaban and begin the other anticoagulant at
to oral the time when the next scheduled dose of rivaroxaban
anticoag would have been adminsitered.
other than
warfarin