to Warfarin

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

to Heparin (CI)

• N/A

to LMWH

• Start LMWH 0-1 hours after heparin

to Dabigatran

• Start Dabigatran ≤2 hours before stopping Heparin

to Apixaban

• Start Apixaban at time of Heparin

to Rivaroxaban

• Start Rivaroxaban at time of Heparin

to Edoxoban

• Start Edoxoban 4 hours after Heparin discontinuation

*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