Switching between anticoagulants

Commence warfarin in combination with apixaban
Apixaban should be continued for 2 days, after which point INR should be measured prior to each dose of apixaban
Apixaban should be discontinued when INR is ≥ 2.0

If CrCl >30 mL/min, wait 12 hours after last dose of dabigatran to initiate parenteral anticoagulant.
If CrCl <​​30 mL/min, wait 24 hours after last dose of dabigatran to initiate parenteral anticoagulant.
In cases of high bleeding risk, consider omitting initial bolus when transitioning to heparin infusion.

• For CrCl ≥ 50ml/minute, commence warfarin 3 days prior to discontinuing dabigatran
• For CrCl 30-50ml/minute, commence warfarin 2 days prior to discontinuing dabigatran
• NB: dabigatran can increase INR. INR measurements should be interpreted cautiously until dabigatran has been stopped for 2 days.

Edoxaban and LMWH should not be administered simultaneously
Discontinue edoxaban and commence LMWH at the time that the next scheduled dose of original drug would be due

• If on 60 mg dose, give 30 mg edoxaban OD plus an appropriate warfarin dose
• If on 30 mg dose, give 15 mg edoxaban OD plus an appropriate warfarin dose
• Patients should not take a loading dose of warfarin in order to promptly achieve a stable INR between 2 and 3.
• Once an INR ≥ 2.0 is achieved, Edoxaban should be discontinued
• Most patients (85%) should be able to achieve an INR ≥ 2.0 within 14 days of concomitant administration
• After 14 days it is recommended that edoxaban is discontinued and the warfarin continued to be titrated to achieve an INR between 2 -3
• It is recommended that during the first 14 days of concomitant therapy the INR is measured at least 3 times just prior to taking the daily dose of edoxaban to minimise the influence of edoxaban on INR measurements

Commence warfarin in combination with LMWH, and monitorINR
Discontinue LMWH once INR in therapeutic range for 2 consecutive days

Commence warfarin in combination with rivaroxaban
Rivaroxaban should be discontinued when INR is in therapeutic range
Measure INR prior to each dose of rivaroxaban being administered

Discontinue warfarin and start edoxaban as soon as INR is <2.5

Treatment of DVT/PE

• Disconinue warfarina and start LMWH when INR ​<2 

Prevention of stroke and systemic embolism

• review thrombotic risk on a case-by-case basis and consider initiating prophylactic or treatment dose LMWH once INR

Rivaroxaban

DVT, PE and prevention of recurrence

• Discontinue warfarin and start rivaroxaban when INR is ≤2.5.

Prevention of stroke and systemic embolism

• Discontinue warfarin and start rivaroxaban when INR ≤3.0.