Switching from a DOAC to warfarin | ||
Dabigatran | Overlap warfarin with dabigatran for 3 days (normal renal function); 2 days (CrCl 30 to 50 mL/min); or 1 day (CrCl 15 to 30 mL/min); note that dabigatran can contribute to INR elevation. -or- Overlap warfarin with dabigatran until the INR is therapeutic on warfarin (ASH).* | |
Apixaban | If continuous anticoagulation is needed, discontinue apixaban and start a parenteral anticoagulant with warfarin; continue the parenteral agent until the INR is therapeutic on warfarin (PI). Note that apixaban can contribute to INR elevation. -or- Overlap warfarin with apixaban until the INR is therapeutic on warfarin, testing right before the next apixaban dose to minimize the effect of apixaban on INR elevation (ASH).* | |
Edoxaban | Reduce dose by half (eg, from 60 to 30 mg daily or from 30 to 15 mg daily) and begin warfarin concurrently (PI). Discontinue edoxaban when the INR is ≥2; note that edoxaban can contribute to INR elevation. -or- Discontinue edoxaban and start a parenteral anticoagulant with warfarin; continue the parenteral agent until the INR is therapeutic on warfarin (PI). -or- Overlap warfarin with edoxaban until the INR is therapeutic on warfarin, testing right before the next edoxaban dose to minimize the effect of edoxaban on INR elevation (ASH).* | |
Rivaroxaban | Discontinue rivaroxaban and start a parenteral anticoagulant with warfarin; continue the parenteral agent until the INR is therapeutic on warfarin (PI). Note that rivaroxaban can contribute to INR elevation. -or- Overlap warfarin with rivaroxaban until the INR is therapeutic on warfarin, testing right before the next rivaroxaban dose to minimize the effect of rivaroxaban on INR elevation (ASH).* | |
Switching from warfarin to a DOAC | ||
Dabigatran | Stop warfarin, monitor the PT/INR, and start dabigatran when the INR is <2 (PI). | |
Apixaban | Stop warfarin, monitor the PT/INR, and start apixaban when the INR is <2 (PI). | |
Edoxaban | Stop warfarin, monitor the PT/INR, and start edoxaban when the INR is ≤2.5 (PI). | |
Rivaroxaban | Stop warfarin, monitor the PT/INR, and start rivaroxaban when the INR is <3 (PI). | |
Switching from one DOAC to a different DOAC | ||
Any DOAC | Start the second DOAC when the next dose of the first DOAC would have been due; do not overlap. |
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