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

Transitioning from Eliquis (Apixaban) to Coumadin (Warfarin)

Stop apixaban and start warfarin immediately at the same time, along with a parenteral anticoagulant (LMWH or UFH), then discontinue the parenteral agent when INR reaches therapeutic range (≥2.0 for 24 hours). 1

Transition Protocol

Step 1: Discontinue Apixaban and Initiate Overlap Therapy

• Stop apixaban at the time you would give the next scheduled dose 1
• Start warfarin at the usual initial dose (typically 5 mg daily, or 2.5 mg if liver disease or interacting medications present) 2
• Simultaneously begin a parenteral anticoagulant at the time of the next scheduled apixaban dose: 2
  • LMWH options:
    • Dalteparin 200 units/kg SC daily 2
    • Enoxaparin 1 mg/kg SC every 12 hours 2
  • UFH options:
    • IV: 80 units/kg bolus, then 18 units/kg/hour, targeting aPTT 2-2.5× control 2
    • SC: 333 units/kg load, then 250 units/kg every 12 hours 2

Step 2: Monitor INR and Continue Overlap

• Continue both warfarin and the parenteral anticoagulant for at least 5 days 2
• Check INR daily during the transition 2
• Do not rely on initial INR measurements during the transition, as apixaban affects INR values 1

Step 3: Discontinue Parenteral Anticoagulant

• Stop the parenteral anticoagulant only when BOTH criteria are met: 2
  • At least 5 days of overlap therapy completed
  • INR ≥2.0 for at least 24 hours (target INR 2.0-3.0) 2

Critical Rationale for This Approach

Unlike transitions between DOACs, the apixaban-to-warfarin transition requires bridging with a parenteral anticoagulant because warfarin takes several days to achieve therapeutic anticoagulation. 1 Apixaban's anticoagulant effect wears off within 24 hours of the last dose, creating a dangerous gap if warfarin is started alone 1. The parenteral anticoagulant provides immediate anticoagulation coverage during the 5-7 days needed for warfarin to reach therapeutic levels 2, 3.

Common Pitfalls to Avoid

• Never start warfarin alone without parenteral anticoagulation coverage - this creates a 5-7 day window of inadequate anticoagulation and increased thrombotic risk 2, 1
• Do not stop the parenteral anticoagulant before achieving therapeutic INR for 24 hours - warfarin's full anticoagulant effect requires depletion of vitamin K-dependent clotting factors, which takes time even after INR rises 2
• Do not use INR values obtained in the first 1-2 days to guide warfarin dosing - apixaban interferes with INR measurements during the transition 1
• Avoid premature discontinuation of anticoagulation during the transition - this significantly increases stroke risk, particularly in atrial fibrillation patients 1

Special Considerations

High Thrombotic Risk Patients

For patients at very high thrombotic risk (recent VTE, mechanical heart valves, high CHADS₂ scores), ensure there is absolutely no gap in anticoagulation coverage by starting the parenteral agent at the exact time the next apixaban dose would have been due 2, 1.

Bleeding Risk Assessment

• Obtain baseline CBC, PT, aPTT, and renal/hepatic function before transition 2
• Assess for concomitant antiplatelet agents or NSAIDs that increase bleeding risk 1
• Consider the patient's HAS-BLED score, though apixaban's bleeding risk is lower than warfarin across all risk categories 4

Duration of Warfarin Therapy

Continue warfarin for the duration appropriate to the indication (minimum 3 months for VTE, indefinite for atrial fibrillation or recurrent VTE) 2.