Can Eliquis Be Given Along with Coumadin Until INR Therapeutic?
No, Eliquis (apixaban) should not be given concurrently with Coumadin (warfarin) while waiting for INR to become therapeutic—this combination significantly increases bleeding risk without established safety data, and the FDA-approved transition protocol specifically avoids overlapping these agents.
FDA-Approved Transition Protocol
When switching from warfarin to apixaban, the official FDA labeling provides clear guidance 1:
- Discontinue warfarin first
- Start apixaban only when the INR falls below 2.0 1
- There is no bridging period or overlap recommended between these two oral anticoagulants 1
This approach directly contradicts the practice of giving both agents simultaneously.
Why Concurrent Use Is Problematic
Apixaban interferes with INR measurements, making warfarin monitoring unreliable during any overlap period 1, 2:
- Apixaban artificially elevates INR values, so measurements during transition "may not be useful for determining the appropriate dose of warfarin" 1
- This creates a dangerous situation where you cannot accurately assess anticoagulation intensity from either agent 2
- The chromogenic anti-Xa assay for apixaban and INR for warfarin measure different aspects of coagulation, making combined monitoring impractical 2
Additive bleeding risk is the primary safety concern 3, 4:
- Both agents independently increase bleeding risk, and combining them compounds this danger 3
- Unlike the warfarin-to-LMWH bridge (which has established safety data), the apixaban-warfarin combination lacks clinical evidence supporting its safety 5
- Apixaban has no antidote readily available in most settings as of the evidence reviewed, making bleeding complications particularly difficult to manage 3
The Correct Reverse Transition (Apixaban to Warfarin)
If you need to switch FROM apixaban TO warfarin, the FDA recommends a different approach that does involve bridging 1:
- Discontinue apixaban
- Start both a parenteral anticoagulant (LMWH or UFH) AND warfarin at the time of the next scheduled apixaban dose 1
- Continue the parenteral agent until INR reaches therapeutic range 1
- This mirrors the traditional approach used when bridging warfarin for high-risk patients 5
This protocol exists because warfarin takes 5-7 days to achieve therapeutic effect, creating a gap in anticoagulation that requires bridging 5.
High-Risk Patients Requiring Bridging
For patients at exceptionally high thrombotic risk who cannot tolerate even brief periods of subtherapeutic anticoagulation when transitioning FROM warfarin TO apixaban 5:
- Mechanical heart valves (though apixaban is contraindicated in mechanical valves) 5
- Recent thromboembolism within 3 months 6
- History of stroke while anticoagulated 6
In these rare scenarios, consider using LMWH as a bridge rather than overlapping oral anticoagulants 5:
- Stop warfarin 5 days before starting apixaban 5
- Begin therapeutic LMWH 2 days after stopping warfarin 5
- Give last LMWH dose 24 hours before starting apixaban 5
- Start apixaban when INR <2.0 1
Common Pitfalls to Avoid
Do not treat apixaban like LMWH in the warfarin transition protocol 1:
- LMWH bridging is standard practice because heparin products don't interfere with INR and have established safety profiles 5
- Apixaban is an oral anticoagulant with different pharmacokinetics and monitoring challenges 1, 2
Do not assume the patient needs continuous therapeutic anticoagulation during the 1-2 day transition 1:
- For most indications (atrial fibrillation, prior VTE on chronic therapy), a brief 24-48 hour gap while waiting for INR <2.0 poses minimal thrombotic risk 5
- The bleeding risk from dual oral anticoagulation likely exceeds the thrombotic risk from this short gap 3, 4
Do not use INR to guide apixaban dosing or assess bleeding risk when both drugs are present 1, 2: