How do I switch from Pradaxa (dabigatran) to Eliquis (apixaban)?

Switching from Pradaxa (Dabigatran) to Eliquis (Apixaban)

Start apixaban at the time the next dose of dabigatran would have been due—no overlap, no gap, and no bridging anticoagulation required.

Timing of the Switch

• Discontinue dabigatran and begin apixaban when the next scheduled dose of dabigatran would be due 1
• The transition should be seamless with no interruption in anticoagulation coverage, as both agents provide immediate anticoagulant effect once therapeutic levels are reached 1
• Do not use bridging anticoagulation with heparin or LMWH during the transition, as this increases bleeding risk without reducing thrombotic risk 2

Dosing Considerations for Apixaban

The appropriate apixaban dose depends on the indication:

For Atrial Fibrillation (Stroke Prevention)

• Standard dose: 5 mg twice daily 1
• Reduced dose: 2.5 mg twice daily if the patient meets at least 2 of the following criteria: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 1

For VTE Treatment

• 10 mg twice daily for 7 days, then 5 mg twice daily for continued treatment 1

For VTE Prophylaxis Post-Surgery

• 2.5 mg twice daily 3

Key Safety Principles

• Unlike warfarin transitions, concurrent administration with parenteral anticoagulants is not recommended when switching between DOACs 1
• Both dabigatran and apixaban have no cross-reactivity concerns and can be switched directly 1
• Apixaban has demonstrated a favorable safety profile with lower gastrointestinal bleeding risk compared to dabigatran in head-to-head comparative effectiveness studies 4

Special Populations Requiring Attention

Renal Impairment

• Assess creatinine clearance before switching, as both agents require dose adjustment in renal dysfunction 1
• Dabigatran is more renally eliminated (80%) than apixaban (27%), so patients with borderline renal function may actually tolerate apixaban better 5

Gastric or Gastroesophageal Lesions

• Apixaban is preferred over dabigatran in patients with gastric or gastroesophageal tumors due to lower bleeding risk 1
• This represents one of the primary clinical scenarios where switching from dabigatran to apixaban is specifically advantageous 1

Common Pitfalls to Avoid

• Never overlap the two DOACs—this creates excessive anticoagulation and bleeding risk 3
• Do not leave a gap between stopping dabigatran and starting apixaban—this creates a period of inadequate anticoagulation and thrombotic risk 1
• Do not use conventional coagulation tests (PT/INR, aPTT) to guide the switch—these are unreliable for monitoring DOAC transitions 5
• Avoid assuming all DOACs are interchangeable without dose adjustment—verify the appropriate apixaban dose for the specific indication 1

Drug Interaction Considerations

• Review concomitant medications, particularly P-glycoprotein inhibitors and CYP3A4 inhibitors, which may require apixaban dose adjustment 3
• Unlike dabigatran, apixaban is metabolized by CYP3A4, so drug interactions differ between these agents 5