From the Guidelines
Transitioning from warfarin to Eliquis (apixaban) should be done by stopping warfarin and starting Eliquis when the INR falls below 2.0, with the standard Eliquis dosage being 5 mg twice daily, unless specific criteria are met for a reduced dose of 2.5 mg twice daily, as guided by the 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation 1. When considering the transition, it's crucial to understand the pharmacokinetic characteristics of both warfarin and apixaban. Warfarin has a half-life of 20-60 hours and is metabolized by CYP2C9, CYP1A2, CYP2C19, and CYP3A4, whereas apixaban has a half-life of 12 hours and is metabolized by CYP3A4 1. Key points to consider during the transition include:
- Checking the patient's INR level before starting Eliquis to determine the appropriate timing for initiation.
- If the INR is below 2.0, Eliquis can be started immediately.
- For INR values between 2.0 and 2.5, warfarin should be discontinued, and Eliquis started 24 hours later.
- For INR values above 2.5, warfarin should be stopped, and the INR checked daily until it falls below 2.0, at which point Eliquis can be initiated.
- The standard Eliquis dosage is typically 5 mg twice daily, but patients with at least two of the following criteria should receive 2.5 mg twice daily: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL, as per the guidelines 1.
- Patient education on the differences between warfarin and Eliquis, including the lack of need for routine blood monitoring with Eliquis and its shorter half-life, is essential for ensuring adherence to the twice-daily dosing schedule. The transition should prioritize minimizing the risk of bleeding or thrombotic events during the changeover period, emphasizing the importance of careful monitoring and timing, as supported by the most recent guidelines 1.
From the FDA Drug Label
Switching from warfarin to apixaban: Warfarin should be discontinued and apixaban started when the international normalized ratio (INR) is below 2. 0. The recommended approach for transitioning from warfarin to apixaban is to discontinue warfarin and start apixaban when the INR is below 2.0 2.
- Key steps:
- Discontinue warfarin
- Start apixaban when INR is below 2.0 It is essential to follow this guidance to ensure a safe transition between these anticoagulants.
From the Research
Transitioning from Warfarin to Eliquis
- The process of transitioning from warfarin to Eliquis (apixaban) involves considering the patient's individual characteristics, such as their international normalized ratio (INR) control and risk of thromboembolism or bleeding 3.
- According to the American College of Chest Physicians, apixaban is indicated for the prevention of systemic embolism and stroke in persons with nonvalvular atrial fibrillation, and can be used as an alternative to warfarin 4.
- Studies have shown that apixaban is effective and safe compared to warfarin, with lower rates of stroke, systemic embolism, major bleeding, and mortality, regardless of the level of predicted INR control 3.
Considerations for Transitioning
- When transitioning from warfarin to apixaban, it is essential to consider the patient's INR control, as apixaban has been shown to be effective across a range of INR levels 3.
- The optimal range of INR for radiofrequency catheter ablation of atrial fibrillation during therapeutic anticoagulation with warfarin is between 2.0 and 3.0, with an optimal range of 2.1 to 2.5 5.
- Patients with poor INR control may benefit from transitioning to apixaban, as it has been shown to be effective in reducing the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, regardless of their INR control 3.
Bridging Anticoagulation
- When transitioning from warfarin to apixaban, bridging anticoagulation with low-molecular-weight heparin or other agents may be necessary to minimize the risk of thromboembolism or bleeding 4, 6.
- The decision to use bridging anticoagulation should be based on the patient's individual risk factors and the specific clinical situation 6.
- Studies have shown that uninterrupted anticoagulation with warfarin during radiofrequency catheter ablation of atrial fibrillation is associated with a lower risk of periprocedural complications than when warfarin is temporarily discontinued 6, 5.