Switching To and From Various Anticoagulants

Thrombophilia and Anticoagulation Clinic, Minneapolis Heart Institute®, Abbott Northwestern Hospital.
Tel: 612-863-6800 | Reviewed August 2016

S414386C 281375 0517 ©2017 ALLINA HEALTH SYSTEM. TM A TRADEMARK OF ALLINA HEALTH SYSTEM.
MINNEAPOLIS HEART INSTITUTE® AND MHI® ARE TRADEMARKS OF MINNEAPOLIS HEART INSTITUTE®, INC.

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 Switching To and From Various Anticoagulants

From To Conversion Recommendation

DOACs*
heparin, bivalirudin, Stop apixaban
or argatroban infusion Begin infusion at time when next dose of apixaban is due

LMWH/subcutaneous agents Stop apixaban

(enoxaparin, fondaparinux, dalteparin) Begin agent at time when next dose of apixaban is due

Stop apixaban
Start warfarin and consider bridging agent at next apixaban due time
warfarin Start INR monitoring 2 days after stopping apixaban (INR values drawn sooner may be falsely
elevated by apixaban)
Apixaban1** Stop bridging agent when INR is at goal

Stop apixaban
dabigatran Begin dabigatran when next dose of apixaban is due

Stop apixaban
edoxaban Begin edoxaban when next dose of apixaban is due

Stop apixaban
rivaroxaban Begin rivaroxaban when next dose of apixaban is due

Stop dabigatran
heparin, bivalirudin, CrCl ≥ 30 mL/min – start infusion 12 hours after last dose of dabigatran
or argatroban infusion
CrCl < 30 mL/min – start infusion 24 hours after last dose of dabigatran
Dabigatran2**
Stop dabigatran
LMWH/subcutaneous agents CrCl ≥ 30 mL/min – start agent 12 hours after last dose of dabigatran
(enoxaparin, fondaparinux, dalteparin) CrCl < 30 mL/min – start agent 24 hours after last dose of dabigatran

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 Switching To and From Various Anticoagulants

From To Conversion Recommendation

DOACs*, continued
CrCl ≥ 50 mL/min, start warfarin 3 days before stopping dabigatran
CrCl 30-49 mL/min, start warfarin 2 days before stopping dabigatran
CrCl 15-29 mL/min, start warfarin 1 day before stopping dabigatran
warfarin CrCl < 15 mL/min, not recommended
Start INR monitoring 2 days after stopping dabigatran (INR values drawn sooner may be falsely
elevated by dabigatran)

Dabigatran2** Stop dabigatran

apixaban Initiate apixaban at the time of the next regularly scheduled dose of dabigatran

Stop dabigatran
edoxaban
Initiate edoxaban at the time of the next regularly scheduled dose of dabigatran

Stop dabigatran
rivaroxaban Initiate rivaroxaban ≤2 hours prior to the next regularly scheduled dose of dabigatran

heparin, argatroban, or Stop edoxaban

bivalirudin infusion Begin infusion at time when next dose of edoxaban is due

LMWH/subcutaneous agents Stop edoxaban

(dalteparin, enoxaparin, fondaparinux) Begin agent at time when next dose of edoxaban is due

If taking 60 mg daily Edoxaban – reduce dose to 30 mg daily and begin warfarin concomitantly.
Discontinue when INR is at goal
If taking 30 mg daily Edoxaban – reduce dose to 15 mg daily and begin warfarin concomitantly.
Edoxaban3** warfarin Discontinue when INR is at goal
OR
Begin parenteral anticoagulant (bridge therapy) and warfarin at the time the next dose of
edoxaban is due. When INR is at goal, discontinue parenteral anticoagulant.

apixaban
Stop edoxaban
dabigatran
Begin DOAC at time when next dose of edoxaban is due
rivaroxaban

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 Switching To and From Various Anticoagulants

From To Conversion Recommendation

DOACs*, continued
heparin, bivalirudin, Stop rivaroxaban
or argatroban infusion Begin infusion at time when next dose of rivaroxaban is due

LMWH/subcutaneous agents Stop rivaroxaban

(enoxaparin, fondaparinux, dalteparin) Begin agent at time when next dose of rivaroxaban is due

Stop rivaroxaban
Start warfarin and consider starting bridging agent at next rivaroxaban due time
Rivaroxaban4** warfarin Start INR monitoring 2 days after stopping rivaroxaban (INR values drawn sooner may be falsely
elevated by rivaroxaban)
Stop bridging agent once goal INR is achieved

apixaban
Stop rivaroxaban
dabigatran
Begin DOAC at time when next dose of rivaroxaban is due
edoxaban

Heparinoids/SC Agents
Stop heparin
Start agent at time heparin infusion is stopped
LMWH, subcutaneous
If more conservative strategy is preferred, start LMWH/SC agent 2 hours after heparin
infusion is stopped

dabigatran
Stop heparin
apixaban
Start DOAC at the time of stopping heparin infusion
rivaroxaban
Heparin Infusion
Stop heparin
edoxaban
Start edoxaban 4 hours after stopping heparin infusion

Begin when clinically indicated

warfarin Can overlap therapy to achieve therapeutic INR
Heparin dosage should decrease as INR increases

Stop heparin
argatroban/bivalirudin infusion
Start infusion immediately after heparin infusion is stopped.

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 Switching To and From Various Anticoagulants

From To Conversion Recommendation

Heparinoids/SC Agents, continued

Stop LMWH/SC agent
heparin infusion
Start heparin infusion at time when next dose of LMWH/SC agent is due

dabigatran Stop LMWH/SC agent

LMWH/ rivaroxaban
Start DOAC ≤2 hours prior to the time of the next scheduled dose of LMWH/SC agent
subcutaneous
(Enoxaparin, apixaban Stop LMWH/SC agent
Dalteparin, Start DOAC at time when next dose of LMWH/SC agent is due
edoxaban
Fondaparinux)
Begin when clinically indicated
warfarin
Can overlap therapy to achieve goal INR

Stop LMWH/SC agent

argatroban/bivalirudin infusion
Start bivalirudin infusion at time when next dose of LMWH/SC agent is due

Vitamin K Antagonists
heparin, argatroban, Stop warfarin
or bivalirudin infusion Initiate infusion when INR < 2

LMWH/subcutaneous agents Stop warfarin

(enoxaparin, fondaparinux, dalteparin) Initiate agent when INR is 2

Stop warfarin
dabigatran
Start dabigatran when INR < 2
Warfarin
Stop warfarin
rivaroxaban
Start rivaroxaban when INR < 3

Stop warfarin
apixaban
Start apixaban when INR < 2

Stop warfarin
edoxaban
Start edoxaban when INR ≤ 2.5

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 Switching To and From Various Anticoagulants

From To Conversion Recommendation

IV Direct Thrombin Inhibitors

If HIT has been ruled out, stop bivalirudin
heparin infusion Start heparin infusion immediately after bivalirudin infusion is stopped. Consider renal function in
making decision.

If HIT has been ruled out, stop bivalirudin

LMWH/subcutaneous agents
Administer agent immediately after bivalirudin infusion is stopped. Consider renal function when
(enoxaparin, fondaparinux, dalteparin)
making decision.

Begin when clinically indicated

warfarin Can overlap therapy to achieve therapeutic CFX
Bivalirudin dosage should decrease as CFX decreases
Bivalirudin
Stop bivalirudin
dabigatran
Start dabigatran at the time of stopping bivalirudin

Stop bivalirudin
apixaban
Start apixaban at the time of stopping bivalirudin

Stop bivalirudin
edoxaban
 Start edoxaban at the time of stopping bivalirudin

Stop bivalirudin
rivaroxaban
 Start rivaroxaban 4 hours after stopping bivalirudin

If HIT has been ruled out, stop argatroban

heparin infusion Start heparin infusion immediately after argatroban is stopped. Consider hepatic function in
making decision.

If HIT has been ruled out, stop argatroban

LMWH, subcutaneous Administer LMWH immediately after argatroban infusion is stopped. Consider hepatic function in
making decision.
Argatroban
Begin when clinically indicated
warfarin Can overlap therapy to achieve therapeutic CFX
Argatroban needs should decrease as CFX decreases

Stop argatroban
dabigatran
Start dabigatran at the time of stopping argatroban

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 Switching To and From Various Anticoagulants

From To Conversion Recommendation

IV Direct Thrombin Inhibitors, continued

Stop argatroban
apixaban
Start apixaban at the time of stopping argatroban

Stop argatroban
Argatroban edoxaban
Start edoxaban at the time of stopping argatroban

Stop argatroban
rivaroxaban
Start rivaroxaban 4 hours after stopping argatroban

* Direct Oral Anticoagulant

** For patients with end-stage renal disease or on intermittent or chronic hemodialysis it is recommended to use warfarin instead of a Direct Oral Anticoagulant
(i.e. dabigatran, apixaban, edoxaban, rivaroxaban)

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 Switching To and From Various Anticoagulants

Dosing Information for DOACs

Refer to the Allina Health Direct Oral Anticoagulants (DOACs) Guide

For detailed prescription information, refer to the manufacturer’s package insert for each medication.

Disclaimer
Guidelines are not meant to replace clinical judgment or professional standards of care. Clinical judgment must take into consideration all the facts in each
individual and particular case, including individual patient circumstances and patient preferences. They serve to inform clinical judgment, not act as a substitute for
it. These guidelines were developed by a Review Organization under Minn. Statutes §145.64 et. seq., and are subject to the limitations described as Minn. Statues
§145.65.

References
1. Apixaban (Eliquis) Package Insert. Product Information: ELIQUIS(R) oral tablets, apixaban oral tablets. Bristol-Myers Squibb Company and Pfizer Inc.,
Princeton, NJ, 2015.
2. Dabigatran Etaxilate (Pradaxa) Package Insert. Product Information: PRADAXA(R) oral capsules, dabigatran etexilate mesylate oral capsules. Boehringer
Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, 2014.
3. Edoxaban (Savaysa) Package Insert. Product Information: SAVAYSA(TM) oral tablets, edoxaban oral tablets. Daiichi Sankyo, Inc., Parsippany, NJ, 2015.
4. Rivaroxaban (Xarelto) Package Insert. Product Information: XARELTO(R) oral tablets, rivaroxaban oral tablets. Janssen Pharmaceuticals, Inc. (per FDA),
Titusville, NJ, 2013.

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