Switching from: 
RIVAROXABAN

Stop rivaroxaban

Start apixaban when next dose of rivaroxaban was due

Stop rivaroxaban

Start edoxaban when next dose of rivaroxaban was due

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Stop rivaroxaban

Start dabigatran 24 hours after last rivaroxaban dose

Stop edoxaban

Start apixaban when next dose of edoxaban was due

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Stop edoxaban

Start rivaroxaban when next dose of edoxaban was due

Stop edoxaban

Start dabigatran when next dose of edoxaban was due

Switching from:
APIXABAN

FORMULARY FIRST LINE CHOICE

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Stop apixaban

Start edoxaban when next dose of apixaban was due

Stop apixaban

Start rivaroxaban when next dose of apixaban was due

Stop apixaban

Start dabigatran when next dose of apixaban was due

Switching from:
WARFARIN

Stop warfarin and check INR the next day. 

Start apixaban when INR ≤2.0

Stop warfarin and check INR the next day. 

Start edoxaban when INR ≤2.5

Stroke & systemic embolism prophylaxis: Stop warfarin and check INR the next day. 
Start rivaroxaban  when INR ≤3

Treatment or prevention of recurrence of DVT/PE: 
Stop warfarin
and check INR the next day. Start rivaroxaban when INR ≤2.5

Stop warfarin and check INR the next day. 

Start dabigatran when INR ≤2.0

Patient must be able to swallow capsule whole. Opening or chewing the capsule increases oral bioavailability and bleeding risk.

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Stop warfarin and check INR the next day. 

Give first dose parenteral anticoagulant when INR ≤2.0

Switching from:
PARENTERAL ANTI-COAGULANT

LMWH: Low molecular weight heparin,  fondaparinux, UH: Unfractionated heparin.

Start apixaban at the next scheduled dose of LMWH or fondaparinux

Start apixaban at the same time that continuous infusion of UH is discontinued

Stop subcutaneous LMWH or fondaparinux Start edoxaban at the time of the next scheduled dose of LMWH or fondaparinux

Start rivaroxaban 0 to 2 hours before the time of the next scheduled dose of LMWH or fondaparinux

Start rivaroxaban at the same time that continuous infusion of UH is discontinued

Start dabigatran 0 to 2 hours before the time of the next scheduled dose of LMWH or fondaparinux

Start dabigatran at the same time that continuous infusion of UH is discontinued

Continue parenteral anticoagulant for at least 5 days and until the INR is above the lower limit of the desired therapeutic range for 24 hours, ie 2 INRs, 24 hours apart.

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Switching from:
APIXABAN

FORMULARY FIRST LINE CHOICE

Give warfarin concurrently with apixaban using standard initial dosing for at least 2 days.

After 2 days co-administration: obtain INR before next dose of apixaban (24 hours after previous dose).

If INR is in target range: stop apixaban and continue warfarin.

If INR is not in target range: continue warfarin and apixaban concurrently until INR is in target range, then stop apixaban.

Warfarin has a slow onset of action. It may take 5 to 10 days before INR is within range.

After apixaban has stopped:
Measure INR after 24 hours to ensure adequate anticoagulation.

Monitor INR closely (eg, once a week) in the first month of warfarin treatment until 3 consecutive, stable INR values (eg, between 2 & 3).

Stop apixaban

Start parenteral anticoagulant when next dose of apixaban was due

NB NOT for concurrent administration

Edoxaban 60mg daily: Give edoxaban 30mg once daily with standard initial dosing of warfarin.

Edoxaban 30mg daily: Give edoxaban 15mg once daily with standard initial dosing of warfarin.

While on both edoxaban and warfarin: measure INR at least 3 times during first 14 days, just before edoxaban daily dose (24 hours after previous dose).

Continue co-administration of edoxaban and warfarin until INR ≥2·0.

Most people should be able to achieve an INR of 2 or more within 14 days of concurrent administration of edoxaban and warfarin.

After 14 days, recommend: discontinue edoxaban. Continue to titrate warfarin to achieve INR between 2 & 3.

After treatment with edoxaban has stopped:
Measure INR after 24 hours to ensure adequate anticoagulation.

Monitor INR closely (once a week) in the first month of warfarin treatment, until 3 consecutive, stable INR values (eg, between 2 &3).

Stop edoxaban

Start parenteral anticoagulant when next dose of edoxaban was due

NB NOT for concurrent administration

Start warfarin and continue rivaroxaban.

For the first 2 days use standard, initial dosing of warfarin, followed by warfarin dosing, guided by INR.

During concurrent treatment with warfarin and rivaroxaban: Measure INR just before next dose of rivaroxaban (24 hours after previous dose).

If INR is in target range (≥2) for 2 concurrent days: stop rivaroxaban and continue warfarin.

If INR is NOT in target range: continue warfarin and rivaroxaban concurrently until INR is in target range.

Warfarin has a slow onset of action. It may take 5 to 10 days before INR is within range.

After  rivaroxaban has stopped:
Measure INR after 24 hours to ensure adequate anticoagulation.

Monitor INR closely (eg, once a week) in the first month of warfarin treatment until 3 consecutive, stable INR values (eg, between 2 & 3).

Stop rivaroxaban

Start parenteral anticoagulant when next dose of rivaroxaban was due. 

NB NOT for concurrent administration

Adjust the starting time of warfarin based on CrCL:

CrCL ≥50 mL/min: start warfarin 3 days before planning to stop dabigatran.

CrCL 30 to 49 mL/min: start warfarin 2 days before planning to stop dabigatran.

After at least 2 days of concurrent treatment with warfarin and dabigatran, measure INR before next dabigatran dose. 

If INR is in target range: Stop dabigatran and continue warfarin.

If INR is NOT in target range: Continue warfarin and dabigatran concurrently until INR is in target range, then stop dabigatran. 

Warfarin has a slow onset of action. It may take 5 to 10 days before INR is within range.

After dabigatran has stopped:
Measure INR after 24 hours to ensure adequate anticoagulation.

Monitor INR closely (eg, once a week) in the first month of warfarin treatment until 3 consecutive, stable INR values (eg, between 2 & 3)

Stop dabigatran

Recommend: Wait at least 12 hours after the last dose of dabigatran before switching to parenteral anticoagulant.

Switching from:
WARFARIN

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Stop warfarin and check INR the next day. 

Give first dose parenteral anticoagulant when INR ≤2.0

Continue parenteral anticoagulant for at least 5 days and until the INR is above the lower limit of the desired therapeutic range for 24 hours, ie, 2 INRs, 24 hours apart.

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