to Warfarin

• Start Warfarin
• Stop LMWH when INR at goal x 48 hours

to Heparin (CI)

• Stop LMWH
• Start CI Heparin without a bolus 0-2 hours before next LMWH dose

to LMWH

• N/A

to Dabigatran

• Stop LMWH
• Start Dabigatran <2 hours before next scheduled dose

to Apixaban

• Stop LMWH
• Start Apixaban at time of next scheduled dose

to Rivaroxaban

• Stop LMWH
• Start Rivaroxaban <2 hours before next scheduled dose

to Edoxoban

• Stop LMWH
• Start Edoxaban at time of next scheduled dose

*Note: Dabigatran, Rivaroxaban, Edoxaban, and Apixaban affect the INR; measuring the INR during coadministration with warfarin therapy may not be useful for determining an appropriate dose of warfarin. To minimize this effect, check INR at trough level of respective medication