How to Transition From Warfarin to a DOAC (Apixaban, Rivaroxaban, Edoxaban)

Last week we covered adjusting Coumadin based on INR and when to consider a switch to a DOAC. This week: how to actually make the transition safely so your patient stays continuously anticoagulated.

The Goal

Maintain stable anticoagulation during the changeover while minimizing bleeding and thromboembolic risk.

Before You Switch: Quick Safety Checklist

• Confirm indication (AF vs. VTE treatment/secondary prevention vs. postop prophylaxis).

• Kidney function: Check eGFR/CrCl. (Apixaban is often preferred in CKD; can be used in ESRD/on dialysis per label/major guidelines. Avoid rivaroxaban/edoxaban with severe renal impairment per labeling.)

• Liver disease: Avoid DOACs in significant hepatic impairment (e.g., Child-Pugh C).

• Pregnancy/Lactation: Warfarin/DOACs are not preferred—consult specialists.

• Drug interactions: Review CYP3A4 & P-gp inducers/inhibitors (e.g., azoles, macrolides, rifampin, anticonvulsants, HIV meds, St. John’s wort).

• Insurance/cost: Many manufacturers offer starter packs or copay support; check patient assistance sites.

When to Start the DOAC (after stopping warfarin)

Warfarin’s effect lingers for days. Stop warfarin, follow INR, and start the DOAC when INR falls to the product-specific threshold:

• Apixaban (Eliquis): start when INR ≤ 2.0

• Dabigatran: start when INR < 2.0

• Edoxaban: start when INR ≤ 2.5

• Rivaroxaban (Xarelto): start when INR ≤ 3.0

If the INR cannot be checked, a pragmatic approach is to hold warfarin for 2–3 days, then start the DOAC (use clinical judgment and confirm as soon as possible with an INR).

No overlap (“bridging”) is needed when switching warfarin → DOAC if you use the INR thresholds above.

Which DOAC? (quick take)

• Apixaban: BID dosing; strong data across CKD spectrum; lower GI bleed signal vs. some comparators in older adults.

• Rivaroxaban: once-daily maintenance for AF/VTE (after initial VTE phase); avoid in severe CKD.

• Edoxaban: once daily after 5–10 days of parenteral anticoagulation for acute VTE; watch for reduced efficacy at CrCl >95 mL/min in AF.

I often choose apixaban in CKD or frail patients because of the dosing flexibility and evidence base.

Apixaban (Eliquis) Dosing – Quick Reference

Always verify renal/hepatic status and interactions before prescribing.

Practical Tips for a Smooth Transition

• Write it down for the patient: “Stop warfarin today. Check INR on ___. Start Eliquis 5 mg BID when INR is ≤2.0 (take first dose that evening).”

• No routine lab monitoring is required with DOACs, but periodic renal/hepatic function checks (e.g., at least annually; more often in CKD/elderly) are wise.

• Missed DOAC dose: Take as soon as remembered the same day and do not double up (follow product-specific instructions).

• High bleeding risk or urgent procedures: Know your local reversal pathways (e.g., andexanet alfa for apixaban/rivaroxaban, 4-factor PCC as alternative per protocols).

Cost & Access

DOACs can be pricey. Try:

• Manufacturer copay cards/patient assistance programs

• Medicare Part D tier exceptions

• Pharmacy discount programs; consider starter packs when available

Patient Message Template (you can paste into the portal)

We’re changing from warfarin to Eliquis to simplify your anticoagulation. Stop warfarin today. We will start Eliquis when your INR is ≤2.0. Your Eliquis dose will be __ mg twice daily. Keep all meds the same unless we message you. Call for bleeding, black stools, severe headache, or new shortness of breath/chest pain. Avoid new over-the-counter or herbal meds without checking with us.

References

• FDA Prescribing Information: Apixaban (Eliquis), Rivaroxaban (Xarelto), Edoxaban (Savaysa/Lixiana).

• AHA/ACC/HRS guideline for AF anticoagulation; ASH and CHEST guidance for VTE management and DOAC use.

• ISTH guidance on DOACs in special populations (CKD, extremes of weight).

• Local health-system protocols for anticoagulant reversal and peri-procedural management.

Come back weekly for new practical posts. Have questions or tough cases?
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