From the Guidelines
Transitioning from warfarin to Xarelto (rivaroxaban) should be done by stopping warfarin and allowing the INR to normalize before starting Xarelto.
Key Considerations
- When transitioning from warfarin to Xarelto, it is essential to consider the patient's risk of thromboembolism and bleeding risk 1.
- For patients at low risk of thromboemboli, stopping warfarin for up to 1 week and allowing the INR to normalize without substituting UFH is a recognized approach 1.
- Xarelto should be started once the INR is below 2.0, although the exact timing may vary depending on individual patient factors.
- The ROCKET AF trial provides some guidance on the management of rivaroxaban before surgical procedures, with rivaroxaban being held for 2 days before elective surgery or invasive procedure and for 24 hours before semiurgent procedures 1.
Clinical Approach
- Clinicians should individualize the approach to transitioning from warfarin to Xarelto based on the patient's specific clinical circumstances, including their thromboembolic and bleeding risks.
- Close monitoring of the patient's INR and clinical status is crucial during the transition period to minimize the risk of adverse events.
- The use of bridging anticoagulation with UFH or LMWH may be considered in patients at higher risk of thromboembolism, although the evidence for this approach is limited 1.
From the FDA Drug Label
Switching from Warfarin to XARELTO - When switching patients from warfarin to XARELTO, discontinue warfarin and start XARELTO as soon as the International Normalized Ratio (INR) is below 3. 0 in adults and below 2. 5 in pediatric patients to avoid periods of inadequate anticoagulation.
To transition from warfarin (Coumadin) to Xarelto (rivaroxaban), discontinue warfarin and start XARELTO when the INR is below 3.0 in adults and below 2.5 in pediatric patients 2.
From the Research
Transitioning from Warfarin to Xarelto (Rivaroxaban)
There are no direct studies on transitioning from warfarin to Xarelto (rivaroxaban) in the provided evidence. However, some studies provide information on the safety and effectiveness of rivaroxaban compared to warfarin, as well as the management of bleeding due to anticoagulants.
Safety and Effectiveness of Rivaroxaban
- Rivaroxaban is a cost-effective alternative to warfarin for the prevention of recurrent venous thromboembolism (VTE) 3
- Rivaroxaban has a predictable pharmacokinetic and pharmacodynamic profile, making it an alternative to warfarin 4
- The use of rivaroxaban should be monitored to increase appropriateness of therapy and improve patient safety 5
Management of Bleeding
- Management of bleeding due to rivaroxaban requires careful adherence to first principles of bleeding care 4
- Unapproved and untested reversal strategies may be required in patients with life-threatening bleeding 4