Transcription of Guidance on converting between anticoagulants
1 Guidance on converting between anticoagulants To Warfarin Rivaroxaban st For initial warfarin dosing refer to Warfarin LMWH (Formulary 1 choice Apixaban Dabigatran From Initiation Protocol NOAC). Warfarin For further advice on converting between Treatment of DVT/PE; stop DVT, PE and prevention of Discontinue warfarin Discontinue warfarin and For the management of anticoagulants contact warfarin and initiate treatment recurrence; stop warfarin and commence commence dabigatran as warfarin during invasive Medicines Information (CGH 3030 GRH 6108) dose LMWH when INR < and initiate rivaroxaban apixaban as soon as soon as INR is < procedures refer to the Prevention of stroke and systemic once INR is INR is < warfarin bridging' *In patients with renal impairment, higher embolism; review thrombotic risk Prevention of stroke and protocol. on a case-by-case basis and systemic embolism; stop than therapeutic plasma concentrations are expected and a longer interval may be consider initiating prophylactic or warfarin and initiate required, contact Medicines Information for treatment dose LMWH once INR rivaroxaban once INR further advice.
2 < LMWH Commence warfarin in combination with Discontinue LMWH and Discontinue LMWH Discontinue LMWH and LMWH, and monitor INR. Discontinue LMWH commence rivaroxaban and commence commence dabigatran once INR in therapeutic range for 2 0-2 hours before the time apixaban at the time 0-2 hours before the consecutive days. that the next scheduled that the next time that the next dose of LMWH would be scheduled dose of scheduled dose of due. LMWH would be due. LMWH would be due. Rivaroxaban Commence warfarin in combination with Discontinue rivaroxaban and Discontinue Discontinue rivaroxaban For advice during rivaroxaban. Rivaroxaban should be commence LMWH at the time that rivaroxaban and and commence invasive procedures, discontinued when INR is in therapeutic the next scheduled dose of commence apixaban at dabigatran at the time refer to Newer range. Measure INR prior to each dose of rivaroxaban would be due. the time that the next that the next scheduled anticoagulants and rivaroxaban being administered.
3 Scheduled dose of dose of rivaroxaban elective procedures rivaroxaban would be would be due*. guideline. due*. Apixaban Commence warfarin in combination with Discontinue apixaban and Discontinue apixaban and Discontinue apixaban For advice during apixaban. Apixaban should be continued for 2 commence LMWH at the time that commence rivaroxaban at and commence invasive procedures, days, after which point INR should be the next scheduled dose of the time that the next dabigatran at the time refer to Newer measured prior to each dose of apixaban. apixaban would be due. scheduled dose of that the next scheduled anticoagulants and Apixaban should be discontinued when INR is apixaban would be due*. dose of apixaban would elective procedures be due*. guideline. Dabigatran Conversion protocol depends on renal Discontinue dabigatran and Discontinue dabigatran Discontinue dabigatran For advice during function. For CrCl 50ml/minute, commence commence LMWH 12-hours after and commence and commence invasive procedures, warfarin 3 days prior to discontinuing the last dose of dabigatran was rivaroxaban at the time apixaban at the time refer to Newer dabigatran.
4 For CrCl 30-50ml/minute, administered. that the next scheduled that the next anticoagulants and commence warfarin 2 days prior to dose of dabigatran would scheduled dose of elective procedures discontinuing dabigatran. NB: dabigatran can be due*. dabigatran would be guideline. increase INR. INR measurements should be due*. interpreted cautiously until dabigatran has been stopped for 2 days. References 1. Summary of Product Characteristics for Xarelto 20mg film-coated tablets. electronic Medicines Compendium. Date of revision of the text: 15/08/2014 2. Summary of Product Characteristics for Eliquis 5mg film-coated tablets. electronic Medicines Compendium. Date of revision of the text: 30/07/2014 3. Summary of Product Characteristics for Pradaxa 150mg hard capsules. electronic Medicines Compendium. Date of revision of the text: 05/11/2014 4. National Institute for Health and Care Excellence (NICE). CG 144. venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing.
5 London: National Clinical Guideline Centre. JUNE 2014. [Accessed on: 01 DEC 2014]. Available from: 5. Heidbuchel H, Verhamme P, Alings M et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace (2013) 15;. 625-651. Links For the management of patients on warfarin prior to surgical procedures please refer to Warfarin bridging' Protocol: Management of Warfarin During Elective Procedures. For the management of patients on NOACs (New oral anticoagulants ) prior to surgical procedures please refer to NOAC bridging' Protocol: Newer anticoagulants and Elective Procedures. For dosing instruction when initiating patients on warfarin please refer to Warfarin Initiation Protocol Action Card. Author: David Richards, Pharmacy. Approved by: Haematology, April 2015. Review date: April 2018.
