What is the proper protocol for transitioning a patient from Coumadin (warfarin) to Eliquis (apixaban)?

Transitioning from Warfarin (Coumadin) to Apixaban (Eliquis)

To transition from warfarin to apixaban, discontinue warfarin and start apixaban when the INR is below 2.0. 1

Step-by-Step Protocol

1. Pre-Transition Assessment

• Check current INR level
• Review patient's indication for anticoagulation
• Assess renal function (creatinine clearance)
• Evaluate for drug interactions, particularly P-glycoprotein (P-gp) and CYP3A4 inhibitors

2. Discontinuation of Warfarin

• Stop warfarin therapy
• Monitor INR daily or every other day until it falls below 2.0
• This typically takes 2-4 days after stopping warfarin, depending on the patient's metabolism and previous INR stability 2

3. Initiation of Apixaban

• Begin apixaban when INR is below 2.0 1
• Do not use bridging anticoagulation during this transition 1
• Standard dosing:
  • For atrial fibrillation: 5 mg twice daily
  • Reduced dose (2.5 mg twice daily) for patients with at least two of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 1
  • For DVT/PE treatment: 10 mg twice daily for 7 days, then 5 mg twice daily 1

4. Post-Transition Monitoring

• No routine INR monitoring is required for apixaban
• Monitor for signs of bleeding or thrombosis
• Assess renal function periodically, especially in elderly patients

Special Considerations

Renal Function

• For patients with creatinine clearance 25-30 mL/min, standard apixaban dosing is appropriate and may cause less bleeding than warfarin 3
• Reduce dose for patients with multiple risk factors as noted above

High Thrombotic Risk Patients

• For patients at high risk of thromboembolism (mechanical heart valves, recent stroke, etc.), consider more frequent INR monitoring during transition 2
• If INR drops below therapeutic range too quickly before apixaban initiation, discuss with specialist whether temporary bridging is needed

Perioperative Management

• If transition is occurring in perioperative context, apixaban should be discontinued at least 48 hours prior to procedures with moderate/high bleeding risk, and at least 24 hours prior to procedures with low bleeding risk 1
• Restart apixaban once adequate hemostasis is established 1

Potential Pitfalls and How to Avoid Them

1. Premature initiation of apixaban

   • Always confirm INR is below 2.0 before starting apixaban
   • Starting apixaban while INR remains elevated increases bleeding risk

2. Drug interactions

   • Reduce apixaban dose by 50% when used with combined P-gp and strong CYP3A4 inhibitors
   • For patients already on reduced dose (2.5 mg twice daily), avoid coadministration with these inhibitors 1

3. Inadequate patient education

   • Instruct patients that unlike warfarin, apixaban:
     • Requires twice daily dosing
     • Does not require routine INR monitoring
     • Has a shorter half-life (missed doses are more critical)
     • Should be taken with or without food

4. Monitoring confusion

   • Remind patients and providers that INR is not used to monitor apixaban therapy
   • Standard coagulation tests may not accurately reflect apixaban's anticoagulant effect

This protocol provides a safe and effective approach to transitioning patients from warfarin to apixaban while minimizing both thrombotic and bleeding risks.