Beth Lofgren, PharmD, BCPS
Beth Lofgren, PharmD, BCPS
Beth Lofgren, PharmD, BCPS, received her PharmD degree from the University of Tennessee at Memphis in 1999, after completing a BS at the University of Tennessee at Martin. She started her pharmacy career in retail and has practiced in home health, long-term care, and hospital pharmacy. She has also been blogging as the Blonde Pharmacist since 2004, focusing on education for peers and provider status for pharmacists.

How to Convert Between Anticoagulants

JANUARY 25, 2015
One of the most common questions from prescribers that I have answered in the past year concerns how to convert from 1 anticoagulant to another, especially following the release of the newer rivaroxaban, apixaban, and dabigatran.

Perhaps the physician wants the patient to avoid multiple labs with warfarin monitoring, or maybe the patient cannot keep his or her vitamin K-rich food intake consistent with warfarin. Whatever the reason, factor Xa inhibitors (apixaban, fondaparinux, and rivaroxaban) and a direct thrombin inhibitor (dabigatran) are chipping into the warfarin market for different indications. 

The biggest thing to keep in mind is how long 1 dose of the anticoagulant lasts. It is also wise to know the patient's renal function in the anticoagulants that are renally adjusted, as well as which anticoagulants affect INR or can affect INR. 

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 then stop LMWH or UFH when INR therapeutic.
LMWH/fonda to apixaban Stop LMWH/fonda and start apixaban 0-2 hours before next LMWH/fonda dose is due.
Heparin to apixaban Stop heparin and start apixaban at the same time.
Apixaban to LMWH/UFH Stop apixaban and start LMWH/UFH at the time when apixaban would have been due.
Apixaban to oral anticoagulant other than warfarin Stop apixaban and begin the other agent at the time when 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 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 dabigatran Stop parenteral anticoagulant and administer dabigatran 0-2 hrs before the next parenteral dose would have been administered.
IV heparin to dabigatran Administer first dose of dabigatran at the 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 mL/min: 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 when 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. However, the manufacturer advises when INR <3.
Rivaroxaban to warfarin Start warfarin and stop rivaroxaban 3 days later, or stop 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/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 when 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 when the next scheduled dose of rivaroxaban would have been adminsitered.
 
 
References
Pradaxa package insert
Eliquis package insert
Xarelto package insert
Alberts MJ, Eikelboom JW, Hankey GJ. Antithrombotic therapy for stroke prevention in non-valvular atrial fibrillation. Lancet Neurology. 2012;11:1066–81.
Schulman S, Crowther MA. How I treat with anticoagulants in 2012: new and old anticoagulants, and when and how to switch. Blood. 2012;119:3016–23.
 


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