Switching Between Anticoagulants
NOAC to LMWH​
Stop NOAC.
Start LMWH when next dose of NOAC would have been due.
LMWH to NOAC​
Stop LMWH.
Start NOAC when next dose of LMWH would have been due.
UFH infusion to NOAC​
Start NOAC at the time of discontinuation of the infusion.
caution
Elimination of heparin may take longer in CKD.
NOAC to NOAC​
Start the alternative NOAC when the next dose is due, except where higher than therapeutic plasma concentrations are expected (e.g. renal impairment). In such cases a longer interval may be expected.
Aspirin or clopidogrel to NOAC​
Start NOAC immediately and stop aspirin or clopidogrel, unless combination therapy is necessary despite increased bleeding risk.
VKA to NOAC​
Stop VKA.
Start NOAC when INR < 2.0.
If INR 2.0 - 2.5, stop VKA and start NOAC after 24 hours.
NOAC to VKA​
Apixaban​
Continue apixaban for ≥ 2 days after beginning VKA.
Obtain an INR prior to the next scheduled dose of apixaban.
Continue co-administration of apixaban with VKA until INR ≥ 2.0.
Re-test INR 24 hours after the last dose of apixaban.
Dabigatran​
If CrCl ≥ 50 mL/min, start VKA 3 days before stoppping dabigatran.
If CrCl ≥ 30 mL/min but < 50 mL/min, start VKA 2 days before stopping dabigatran.
Re-test INR 24 hours after last dose of dabigatran.
info
Dabigatran can increase INR. The INR will better reflect the effect of warfarin 2 days after dabigatran is discontinued. Until then, INR values should be interpreted with caution.
Rivaroxaban​
Start VKA at standard initial dosing with rivaroxaban.
Adjust VKA dose as guided by INR testing (insensitive to rivaroxaban in assays at Barts Health).
Obtain an INR immediately prior to the next scheduled dose of rivaroxaban.
Continue co-administration of rivaroxaban with VKA until INR ≥ 2.0.
Re-test INR 24 hours after the last dose of rivaroxaban.