How do I transition a patient from Eliquis (apixaban) to warfarin?

Transitioning from Apixaban (Eliquis) to Warfarin

When transitioning from apixaban to warfarin, discontinue apixaban and begin both a parenteral anticoagulant and warfarin at the time the next dose of apixaban would have been taken, then discontinue the parenteral anticoagulant when INR reaches an acceptable range. 1

Rationale and Process

Transitioning between anticoagulants requires careful management to maintain effective anticoagulation while minimizing bleeding risk. The FDA-approved labeling for apixaban provides specific guidance for this transition:

Step-by-Step Approach:

1. Discontinue apixaban

   • Note that apixaban affects INR measurements, making initial INR readings during transition unreliable for determining appropriate warfarin dosing 1

2. Begin bridging therapy:

   • At the time when the next dose of apixaban would have been taken:
     • Start warfarin
     • Simultaneously start a parenteral anticoagulant (typically low molecular weight heparin such as enoxaparin or unfractionated heparin)

3. Monitor INR:

   • Check INR daily during the transition period
   • Continue both warfarin and the parenteral anticoagulant until the INR reaches the target therapeutic range (typically 2.0-3.0)

4. Discontinue parenteral anticoagulant:

   • Once the INR is in therapeutic range (≥2.0 for 24 hours), discontinue the parenteral anticoagulant
   • Continue warfarin with regular INR monitoring

Specific Parenteral Anticoagulant Options

When bridging with parenteral anticoagulants, the 2018 NCCN guidelines provide dosing options 2:

LMWH Options:

• Dalteparin: 200 units/kg SC daily
• Enoxaparin: 1 mg/kg SC every 12 hours

Unfractionated Heparin Options:

• UFH IV: 80 units/kg load, then 18 units/kg/h, target aPTT of 2-2.5× control
• UFH SC: 333 units/kg load, then 250 units/kg every 12 hours

Important Considerations and Pitfalls

Potential Complications:

• Increased stroke risk: The transition period from apixaban to warfarin carries an increased risk of thrombotic events 1
• Bleeding risk: Overlapping anticoagulants may increase bleeding risk, requiring careful monitoring

Special Populations:

• For patients with renal impairment, dose adjustment of the parenteral anticoagulant may be necessary
• For patients at high bleeding risk, more frequent INR monitoring is advisable
• Consider aiming for the lower end of the INR target range (2.0-2.5) initially 2

Common Pitfalls to Avoid:

1. Relying on INR alone during transition: INR is affected by apixaban and may not accurately reflect warfarin's anticoagulant effect initially
2. Discontinuing apixaban too early: Maintain anticoagulation coverage throughout the transition
3. Delaying parenteral anticoagulant: The bridging agent should be started simultaneously with warfarin
4. Inadequate monitoring: INR should be checked frequently during transition

Follow-up and Monitoring

After successful transition to warfarin:

• Monitor INR regularly to maintain target range (2.0-3.0)
• Adjust warfarin dose as needed based on INR results
• Educate patient about diet, medication interactions, and signs of bleeding or thrombosis

By following this structured approach, the transition from apixaban to warfarin can be accomplished safely while maintaining effective anticoagulation throughout the process.