From the Guidelines
To transition from warfarin to Pradaxa (dabigatran), stop warfarin and check the INR daily until it falls below 2.0, then start Pradaxa, as recommended by the 2012 focused update of the ESC guidelines for the management of atrial fibrillation 1. When switching from a VKA to a NOAC like Pradaxa, it is crucial to allow the INR to fall to about 2.0 before starting the NOAC, considering the rapid onset of anticoagulation effect of these drugs 1.
- For patients with normal kidney function, begin Pradaxa 150 mg twice daily once the INR is below 2.0.
- For elderly patients (over 80 years) or those with increased bleeding risk, use the lower dose of 110 mg twice daily, as suggested by the 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation 1.
- Patients with reduced kidney function (CrCl 30-50 mL/min) should also receive the lower dose, and Pradaxa is contraindicated if CrCl is below 30 mL/min, as indicated in the study 1. The transition period varies based on the patient's current INR and warfarin half-life, typically taking 2-5 days after stopping warfarin, and no bridging with heparin is typically needed 1. It is essential to instruct patients to take Pradaxa with food to reduce gastrointestinal side effects and to understand that Pradaxa must be taken twice daily without missing doses due to its shorter half-life compared to warfarin 1. Additionally, patients should be aware that standard INR monitoring cannot be used with Pradaxa, as it does not affect this test 1. Compliance and adherence to treatment are crucial, especially since Pradaxa has a relatively short half-life, and missing more than one dose could leave patients without anticoagulation protection 1.
From the FDA Drug Label
When converting patients from warfarin therapy to PRADAXA Capsules, discontinue warfarin and start PRADAXA Capsules when the INR is below 2. 0.
To transition from warfarin to pradaxa, discontinue warfarin and start pradaxa when the INR is below 2.0 2.
- The patient should be switched from warfarin to pradaxa when the INR is less than 2.0.
- No specific dosing adjustments are recommended for the transition from warfarin to pradaxa based on the INR value, as long as it is below 2.0.
- It is essential to follow the recommended dosage and administration instructions for pradaxa to ensure safe and effective use.
From the Research
Transitioning from Warfarin to Pradaxa (Dabigatran)
- The decision to transition from warfarin to Pradaxa (dabigatran) should be based on individual patient characteristics and medical history, as well as the specific indications and contraindications for each medication 3, 4, 5, 6, 7.
- Studies have shown that dabigatran is effective in preventing stroke and systemic embolism in patients with nonvalvular atrial fibrillation, with a similar or lower risk of major bleeding compared to warfarin 3, 5, 6, 7.
- The risk of intracranial bleeding is lower with dabigatran compared to warfarin, which is a significant advantage for patients at high risk of bleeding 3, 5, 6, 7.
Key Considerations
- When transitioning from warfarin to dabigatran, it is essential to consider the patient's renal function, as dabigatran is contraindicated in patients with severe renal impairment 4, 5, 6.
- The dosage of dabigatran should be adjusted based on the patient's renal function and other factors, such as age and body weight 4, 5, 6.
- Patients should be closely monitored for signs of bleeding or other adverse effects after transitioning to dabigatran 3, 5, 6, 7.
Comparison with Other Direct Oral Anticoagulants
- Dabigatran has been compared to other direct oral anticoagulants, such as rivaroxaban and apixaban, in terms of effectiveness and safety in patients with nonvalvular atrial fibrillation 3, 5, 6.
- The results of these studies suggest that dabigatran is similar to or has a lower risk of major bleeding compared to rivaroxaban and apixaban, although the specific findings vary depending on the study population and design 3, 5, 6.