Switching between oral anticoagulants

Switching from a DOAC to warfarin
Dabigatran		Overlap warfarin with dabigatran for 3 days (normal renal function); 2 days (CrCl 30 to 50 mL/min); or 1 day (CrCl 15 to 30 mL/min); note that dabigatran can contribute to INR elevation. -or- Overlap warfarin with dabigatran until the INR is therapeutic on warfarin (ASH).*
Apixaban		If continuous anticoagulation is needed, discontinue apixaban and start a parenteral anticoagulant with warfarin; continue the parenteral agent until the INR is therapeutic on warfarin (PI). Note that apixaban can contribute to INR elevation. -or- Overlap warfarin with apixaban until the INR is therapeutic on warfarin, testing right before the next apixaban dose to minimize the effect of apixaban on INR elevation (ASH).*
Edoxaban		Reduce dose by half (eg, from 60 to 30 mg daily or from 30 to 15 mg daily) and begin warfarin concurrently (PI). Discontinue edoxaban when the INR is ≥2; note that edoxaban can contribute to INR elevation. -or- Discontinue edoxaban and start a parenteral anticoagulant with warfarin; continue the parenteral agent until the INR is therapeutic on warfarin (PI). -or- Overlap warfarin with edoxaban until the INR is therapeutic on warfarin, testing right before the next edoxaban dose to minimize the effect of edoxaban on INR elevation (ASH).*
Rivaroxaban		Discontinue rivaroxaban and start a parenteral anticoagulant with warfarin; continue the parenteral agent until the INR is therapeutic on warfarin (PI). Note that rivaroxaban can contribute to INR elevation. -or- Overlap warfarin with rivaroxaban until the INR is therapeutic on warfarin, testing right before the next rivaroxaban dose to minimize the effect of rivaroxaban on INR elevation (ASH).*
Switching from warfarin to a DOAC
Dabigatran		Stop warfarin, monitor the PT/INR, and start dabigatran when the INR is <2 (PI).
Apixaban		Stop warfarin, monitor the PT/INR, and start apixaban when the INR is <2 (PI).
Edoxaban		Stop warfarin, monitor the PT/INR, and start edoxaban when the INR is ≤2.5 (PI).
Rivaroxaban		Stop warfarin, monitor the PT/INR, and start rivaroxaban when the INR is <3 (PI).
Switching from one DOAC to a different DOAC
Any DOAC		Start the second DOAC when the next dose of the first DOAC would have been due; do not overlap.

This table presents a reasonable approach to switching between oral anticoagulants. It does not substitute for clinical judgment regarding individual patient risks of thrombosis and bleeding. Individuals switching from a DOAC to warfarin are more likely to require continuous anticoagulation if they have had a recent thromboembolic event or if they are at especially high risk of thromboembolism. Refer to UpToDate topics on specific indications, perioperative management, and the use of DOACs and warfarin for further details.

DOAC: direct oral anticoagulant; CrCl: creatinine clearance; INR: international normalized ratio; ASH: American Society of Hematology clinical practice guideline; PI: package insert; PT: prothrombin time.
* Two to three days of overlap after the INR becomes therapeutic may be needed in individuals with higher thrombosis risk, because the PT/INR will enter the therapeutic range before full anticoagulation occurs. In individuals overlapping warfarin and a DOAC, the DOAC may contribute to INR elevation.

Prepared with information from:

Witt DM, Nieuwlaat R, Clark NP, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: Optimal management of anticoagulation therapy. Blood Adv 2018; 2:3257.
PRADAXA (dabigatran etexilate mesylate) capsules. US FDA approval 2010. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/022512s035lbl.pdf (Accessed on April 25, 2019).
ELIQUIS (apixaban) tablets. US FDA approval 2012. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/202155s020lbl.pdf (Accessed on April 25, 2019).
SAVAYSA (edoxaban) tablets. US FDA approval 2015. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/206316s012lbl.pdf (Accessed on April 25, 2019).
XARELTO (rivaroxaban) tablets. US FDA approval 2011. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/022406s030s032lbledt.pdf (Accessed on April 25, 2019).

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