Argatroban
| From | To | Action |
| Argatroban |
Bivalirudin/ Dalteparin/ Enoxaparin/ Fondaparinux/ Heparin | Initiate parenteral anticoagulant within 2 hours after discontinuation of argatroban |
| Apixaban/ Betrixaban Dabigatran/ Edoxaban/ Ravaroxaban | Initiate apixaban, betrixaban, dabigatran, edoxaban, or rivaroxaban within 2 hours after discontinuation of argatroban infusion | |
| Warfarin |
Argatroban must be continued when warfarin is initiated and co-administration should continue for at least 5 days. Do NOT give loading dose of warfarin. There is potential for combined effects on INR with the co-administration of argatroban and warfarin. Initiate warfarin at a low maintenance dose (maximum of 5 mg unless patient was stable on prior doses > 5 mg). Obtain daily INR with co-administration of argatroban and warfarin, and adjust warfarin dose for approximate INR goal of *4-5 during the first 5 days of concomitant argatroban and warfarin therapy. After 5 days of co-therapy with warfarin and argatroban, decrease argatroban rate to 2 mcg/kg/min (if >2 mcg/kg/min) and check INR:
*Note, the above target INR when on combined therapy may vary from patient to patient, but in general need to typically target a higher INR during the switch. Can also consider chromogenic factor X (<30-45%), which predicts an INR of 2.0 or higher. |
Bivalirudin
- The patient should be on a bridge anticoagulant (i.e. heparin or enoxaparin) at the same time to avoid warfarin induced skin necrosis or other thrombotic complications. See separate anticoagulant-specific Clinical Case Manual for transitioning from another specific anticoagulant to warfarin.
- Continue the bridge anticoagulant until INR is within therapeutic range.
- See table for switching from warfarin to another anticoagulant:
| From | To | Action |
| Bivalirudin | Argatroban/ Dalteparin/ Enoxaparin/ Fondaparinux/ Heparin | Initiate parenteral anticoagulant within 2 hours after discontinuation of bivalirudin |
| Apixaban/ Betrixaban Dabigatran/ Edoxaban/ Ravaroxaban | Initiate apixaban, betrixaban, dabigatran, edoxaban, or rivaroxaban within 2 hours after discontinuation of bivalirudin infusion | |
| Warfarin | Bivalirudin must be continued when warfarin is initiated and co-administration should continue for at least 5 days. There is potential for combined effects on INR with the co-administration of bivalirudin and warfarin. A loading dose of warfarin shouldn’t be used. Obtain daily INR with co-administration of bivalirudin and warfarin. After 5 days of co-therapy with warfarin and when INR is *4-5 on combined therapy for at least 1-2 consecutive INR, temporarily suspend the bivalirudin for 4 hours, then check the INR: If INR > 4, discontinue bivalirudin, consider warfarin dose adjustment, and recheck INR in 4-6 hours If INR within desired therapeutic range, discontinue bivalirudin and continue warfarin as per warfarin dosing guidelines If INR < desired therapeutic range, resume bivalirudin at previous rate and increase warfarin dosing as per warfarin guidelines. Recheck INR daily as above. *Note, the above target INR when on combined therapy may vary from patient to patient, but in general need to typically target a higher INR during the switch. Can also consider obtaining factor X activity (~13-23%) or chromogenic factor X (~20-40%) that correlates with INR of 2-3. |
Dabigatran
- A bridge anticoagulant is not necessary when transitioning from another anticoagulant to dabigatran therapy. See separate anticoagulant-specific Clinical Case Manual for transitioning from another specific anticoagulant to dabigatran.
- See table for switching from dabigatran to another anticoagulant
| From | To | Action |
| Dabigatran | Argatroban/Bivalirudin/Enoxaparin/Dalteparin/Fondaparinux/Heparin | Initiate parenteral anticoagulant when next dose of dabigatran would be due. If patient’s CrCl has reduced while on dabigatran, a longer wash out period may be needed before starting new anticoagulant. In cases of increased bleeding risk, consider a risk benefit analysis before omitting initial bolus when transitioning to heparin infusion. |
| Apixaban, Betrixaban Edoxaban, or Rivaroxaban | Initiate when the next dose of dabigatran would have been taken. If patient’s CrCl has reduced while on dabigatran, longer wash out period may be needed before starting new anticoagulant. | |
| Warfarin | Limited data available on switching DOACs to warfarin. Consider coadministering DOAC and warfarin therapy until INR is therapeutic, or stopping DOAC and bridging warfarin with LMWH or UFH if bridging patient is clinically indicated (e.g., start UFH or therapeutic LMWH and warfarin when next dose of rivaroxaban would have been taken).. For normal CrCl, start warfarin 3 days before discontinuing dabigatran. For reduced CrCl 30-50 mL/min, consider starting warfarin 1-2 days before discontinuing dabigatran. All DOACs affect INR so that initial INR during the transition may not be useful for determining the appropriate dose of warfarin. |
Enoxaparin
- See separate anticoagulant-specific Clinical Case Manual for transitioning from another specific anticoagulant to enoxaparin.
- See table for switching from enoxaparin to another anticoagulant
| From | To | Action |
| Enoxaparin | Argatroban/ Bivalirudin/ Dalteparin/ Fondaparinux/ Heparin | From therapeutic enoxaparin: Stop enoxaparin, and initiate parenteral anticoagulant no earlier than 8 hours after the last enoxaparin dose. If UFH is started ≥12 hours following last enoxaparin dose, an UFH bolus dose is generally indicated. In cases of increased bleeding risk, consider a risk benefit analysis before omitting initial bolus when transitioning to heparin infusion. From prophylactic enoxaparin: Initiate parenteral anticoagulant as clinically needed irrespective of time of last enoxaparin dose. In cases of increased bleeding risk, consider a risk benefit analysis before omitting initial bolus when transitioning to heparin infusion. |
| Apixaban, Betrixaban Dabigatran, Edoxaban, or Rivaroxaban | From therapeutic enoxaparin: Stop enoxaparin and initiate apixaban, betrixaban, dabigatran, edoxaban, or rivaroxaban when next enoxaparin dose is expected to be given. From prophylactic enoxaparin doses: Stop enoxaparin and initiate apixaban, betrixaban, dabigatran, edoxaban, or rivaroxaban as clinically indicated irrespective of time of last enoxaparin dose. | |
| Warfarin | From therapeutic enoxaparin: Overlap therapeutic dose enoxaparin with warfarin for at least 5 days AND until INR is in therapeutic range. Consider waiting for 2 consecutive therapeutic INRs for higher risk patients or when initiating warfarin. From prophylactic enoxaparin AND assuming patient does not have a new thrombosis: If immediate therapeutic anticoagulation is not desired, stop enoxaparin and initiate warfarin as clinically needed irrespective of time of last enoxaparin dose. |
Fondaparinux
- See separate anticoagulant-specific Clinical Case Manual for transitioning from another specific anticoagulant to fondaparinux.
- See table for switching from enoxaparin to another anticoagulant
| From | To | Action |
| Fondaparinux |
Argatroban/ Bivalirudin/ Dalteparin/ Enoxparin/ Heparin |
From therapeutic fondaparinux: Initiate parenteral anticoagulant when next fondaparinux dose is expected to be given. In cases of high bleeding risk, consider omitting initial bolus when transitioning to heparin infusion. From prophylaxis fondaparinux: Initiate parenteral anticoagulant as clinically needed irrespective of time of last fondaparinux dose |
| Apixaban, Betrixaban Dabigatran, Edoxaban, or Rivaroxaban |
From therapeutic fondaparinux: Initiate when next fondaparinux dose is expected to be given. From prophylaxis fondaparinux: Initiate as clinically indicated irrespective of time of fondaparinux dose. | |
| Warfarin |
From therapeutic fondaparinux: Overlap therapeutic dose fondaparinux with warfarin for at least 5 days AND until INR is in therapeutic range for at least 24 hours. From prophylaxis fondaparinux AND assuming patient does not have a new thrombosis: Initiate warfarin as clinically indicated irrespective of time of fondaparinux dose |
Rivaroxaban
- A bridge anticoagulant is not necessary when transitioning from another anticoagulant to rivaroxaban therapy. See separate anticoagulant-specific Clinical Case Manual for transitioning from another specific anticoagulant to rivaroxaban.
- See table for switching from rivaroxaban to another anticoagulant
| From | To | Action |
| Rivaroxaban | Argatroban/Bivalirudin/ Enoxaparin/Fondaparinux/ Heparin | Discontinue rivaroxaban and give the first dose of the other anticoagulant at the time that next rivaroxaban would be due. In cases of high bleeding risk, consider omitting initial bolus when transitioning to heparin infusion. |
| Apixaban, Betrixaban, Dabigatran, or Edoxaban | Discontinue rivaroxaban and give the first dose of the other anticoagulant at the time that the next rivaroxaban dose would have been taken. | |
| Warfarin | Limited data available on switching DOACs to warfarin. Consider coadministering DOAC and warfarin therapy until INR is therapeutic, or stopping DOAC and bridging warfarin with LMWH or UFH if bridging patient is clinically indicated (e.g., start UFH or therapeutic LMWH and warfarin when next dose of rivaroxaban would have been taken). Rivaroxaban can elevate the INR and can complicate INR interpretation, therefore rivaroxaban should be stopped when starting warfarin and consider starting enoxaparin at the time of the next scheduled dose of rivaroxaban until INR ≥ 2. All DOACs affect INR so that initial INR during the transition may not be useful for determining the appropriate dose of warfarin; the INR may be affected by rivaroxaban for 24 hours. Consider starting warfarin and stopping rivaroxaban 3 days later. |
Unfractionated Heparin (UH)
- See separate anticoagulant-specific Clinical Case Manual for transitioning from another specific anticoagulant to heparin.
- See table for switching from enoxaparin to another anticoagulant
| From | To | Action |
| Unfractionated Heparin (UH) | Argatroban/ Bivalirudin/ Dalteparin/ | Initiate parenteral anticoagulant within 2 hours after discontinuing heparin infusion. Can stop UFH 0-4 hours after 1st enoxaparin dose. |
| Enoxaparin/ Fondaparinux/ Apixaban, Betrixaban Dabigatran, Edoxaban, or Rivaroxaban | Initiate within 2 hours after discontinuation of heparin infusion. Can start DOAC concurrently with UFH discontinuation. | |
| Warfarin | Overlap therapeutic heparin dose with warfarin for at least 5 days AND until INR is in therapeutic range for 2 consecutive days in a row. |
Wafarin
- The patient should be on a bridge anticoagulant (i.e. heparin or enoxaparin) at the same time to avoid warfarin induced skin necrosis or other thrombotic complications. See separate anticoagulant-specific Clinical Case Manual for transitioning from another specific anticoagulant to warfarin.
- Continue the bridge anticoagulant until INR is within therapeutic range.
- See table for switching from warfarin to another anticoagulant:
| From | To | Action |
| Warfarin | LMWH | Stop warfarin and start LMWH on the 3rd day of holding warfarin. Patients with higher clotting risk may be started on LMWH immediately upon discontinuation of warfarin. |
| UFH | Stop warfarin and start UFH on the 3rd day of holding warfarin or when INR </= 2.0 | |
| Apixaban, Dabigatran | Stop warfarin and start apixaban or dabigatran when INR is <2 | |
| Edoxaban | Stop warfarin and start edoxaban when INR is ≤2.5 | |
| Rivaroxaban | Stop warfarin and start rivaroxaban when INR is <3 |
