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This information is to provides a reasonable starting point for most patients but the clinical background of each patient must be considered before applying the guidance.

If unsure, seek specialist advice.

The guidance only applies to patients receiving anticoagulation for prophylaxis for stroke and systemic embolism in non-valvular AF or patients treated for DVT and prevention of recurrent DVT and PE.
For other indications, or for high-risk patients (such as those with artificial heart valves or those with target INRs above 3·0), seek specialist advice.
Prescribers should check the BNF or SPC for further information on prescribing for each individual drug.
Usually there is no need for parenteral anticoagulants when initiating oral anticoagulants in patients with atrial fibrillation only.

Switching FROM one DOAC TO another DOAC

	To: APIXABAN FIRST LINE	To: EDOXABAN	To: RIVAROXABAN	To: DABIGATRAN
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	⊗	Stop rivaroxaban Start dabigatran 24 hours after last rivaroxaban dose
Switching from: EDOXABAN	Stop edoxaban Start apixaban when next dose of edoxaban was due	⊗	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	⊗	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

To: APIXABAN
FIRST LINE

To: EDOXABAN

To: RIVAROXABAN

To: DABIGATRAN

Switching from:
DABIGATRAN

Stop dabigatran

Start apixaban when next dose of dabigatran was due

Stop dabigatran

Start edoxaban when next dose of dabigatran was due

Stop dabigatran

CrCL ≥50 mL/min: start rivaroxaban 24 hours after last dose of dabigatran.

CrCL 30 to 49mL/min: start rivaroxaban 48 hours after last dose of dabigatran.

CrCL <30mL/min: start rivaroxaban 3 to 4 days after last dose of dabigatran.

⊗

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

⊗

Stop rivaroxaban

Start dabigatran 24 hours after last rivaroxaban dose

Switching from:
EDOXABAN

Stop edoxaban

Start apixaban when next dose of edoxaban was due

⊗

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

⊗

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 or parenteral anticoagulant

	To: APIXABAN FIRST LINE	To: EDOXABAN	To: RIVAROXABAN	To: DABIGATRAN	To: WARFARIN	To: PARENTERAL ANTI-COAGULANT
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.	⊗	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 Stop UH infusion Start edoxaban 4 hours later	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. Stop the parenteral anticoagulant immediately if INR is greater than the upper limit of the desired therapeutic range.	⊗

To: APIXABAN
FIRST LINE

To: EDOXABAN

To: RIVAROXABAN

To: DABIGATRAN

To: WARFARIN

To: PARENTERAL ANTI-COAGULANT

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.

⊗

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

Stop UH infusion
Start edoxaban 4 hours later

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.

Stop the parenteral anticoagulant immediately if INR is greater than the upper limit of the desired therapeutic range.

⊗

Switching TO warfarin or parenteral anticoagulant

	To: WARFARIN	To: PARENTERAL ANTI-COAGULANT
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
Switching from: EDOXABAN	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
Switching from: RIVAROXABAN	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
Switching from: DABIGATRAN	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	⊗	Stop warfarin and check INR the next day. Give first dose parenteral anticoagulant when INR ≤2.0
Switching from: PARENTERAL ANTI-COAGULANT	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. Stop the parenteral anticoagulant immediately if INR is greater than the upper limit of the desired therapeutic range.	⊗

To: WARFARIN

To: PARENTERAL ANTI-COAGULANT

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

Switching from:
EDOXABAN

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

Switching from:
RIVAROXABAN

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

Switching from:
DABIGATRAN

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

⊗

Stop warfarin and check INR the next day.

Give first dose parenteral anticoagulant when INR ≤2.0

Switching from:
PARENTERAL ANTI-COAGULANT

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.

Stop the parenteral anticoagulant immediately if INR is greater than the upper limit of the desired therapeutic range.

⊗

Combined quick reference guide

	APIXABAN FIRST LINE	EDOXABAN	RIVAROXABAN	DABIGATRAN	WARFARIN	PARENTERAL ANTI-COAGULANT
APIXABAN FORMULARY FIRST LINE CHOICE	⊗	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	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	Stop edoxaban Start apixaban when next dose of edoxaban was due	⊗	Stop edoxaban Start rivaroxaban when next dose of edoxaban was due	Stop edoxaban Start dabigatran when next dose of edoxaban was due	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
RIVAROXABAN	Stop rivaroxaban Start apixaban when next dose of rivaroxaban was due	Stop rivaroxaban Start edoxaban when next dose of rivaroxaban was due	⊗	Stop rivaroxaban Start dabigatran 24 hours after last rivaroxaban dose	Give warfarin concurrently with rivaroxaban until INR ≥2·0 for 2 days. Start warfarin and continue rivaroxaban. For the first 2 days use standard, initial dosing of warfarin, followed by warfarin dosing, guided by INR testing. While on both rivaroxaban and warfarin: test INR just before next rivaroxaban dose (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. During concurrent treatment with warfarin and rivaroxaban: Measure INR just before next dose of rivaroxaban. 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
DABIGATRAN	Stop dabigatran Start apixaban when next dose of dabigatran was due	Stop dabigatran Start edoxaban when next dose of dabigatran was due	Stop dabigatran CrCL ≥50 mL/min: start rivaroxaban 24 hours after last dose of dabigatran. CrCL 30 to 49mL/min: start rivaroxaban 48 hours after last dose of dabigatran. CrCL <30mL/min: start rivaroxaban 3 to 4 days after last dose of dabigatran.	⊗	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 Wait at least 12 hours after the last dose of parenteral anticoagulant before switching.
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.	⊗	Stop warfarin and check INR the next day. Give first dose parenteral anticoagulant when INR ≤2.0
PARENTERAL ANTI-COAGULANT	Stop subcutaneous LMWH or fondaparinux Start apixaban at the next scheduled dose of LMWH or fondaparinux Start apixaban at the same time of discontinuation of a continuous infusion of unfractionated heparin	Stop subcutaneous LMWH or fondaparinux Start edoxaban at the time of the next scheduled dose of LMWH or fondaparinux Stop unfractionated heparin infusion Start edoxaban 4 hours later	Start rivaroxaban 0 to 2 hours before the time of the next scheduled dose of LMWH or fondaparinux Start rivaroxaban at the same time of discontinuation of a continuous infusion of unfractionated heparin	Start dabigatran 0 to 2 hours before the time of the next scheduled dose of LMWH or fondaparinux Start dabigatran at the same time of discontinuation of a continuous infusion of unfractionated heparin	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. Stop the parenteral anticoagulant immediately if INR is greater than the upper limit of the desired therapeutic range.	⊗

APIXABAN
FIRST LINE

EDOXABAN

RIVAROXABAN

DABIGATRAN

WARFARIN

PARENTERAL ANTI-COAGULANT

APIXABAN

FORMULARY FIRST LINE CHOICE

⊗

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

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

Stop edoxaban

Start apixaban when next dose of edoxaban was due

⊗

Stop edoxaban

Start rivaroxaban when next dose of edoxaban was due

Stop edoxaban

Start dabigatran when next dose of edoxaban was due

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

RIVAROXABAN

Stop rivaroxaban

Start apixaban when next dose of rivaroxaban was due

Stop rivaroxaban

Start edoxaban when next dose of rivaroxaban was due

⊗

Stop rivaroxaban

Start dabigatran 24 hours after last rivaroxaban dose

Give warfarin concurrently with rivaroxaban until INR ≥2·0 for 2 days.

Start warfarin and continue rivaroxaban.

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

While on both rivaroxaban and warfarin: test INR just before next rivaroxaban dose (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.

During concurrent treatment with warfarin and rivaroxaban: Measure INR just before next dose of rivaroxaban.