Bridging from Warfarin to Apixaban (Eliquis)
Stop warfarin and start apixaban when the INR falls below 2.0—no heparin bridging is required for this transition. 1
Direct Transition Protocol
The FDA-approved apixaban label provides the clearest guidance for this transition 1:
- Discontinue warfarin and monitor the INR
- Start apixaban at the standard dose (typically 5 mg twice daily for atrial fibrillation, or 2.5 mg twice daily if dose reduction criteria are met) when the INR drops below 2.0 1
- No bridging anticoagulation with heparin or low-molecular-weight heparin is necessary during this transition 1
Dose Selection for Apixaban
For atrial fibrillation, use 5 mg twice daily as the standard dose 1. Reduce to 2.5 mg twice daily only if the patient meets at least 2 of these 3 criteria 1:
- Age ≥80 years
- Body weight ≤60 kg
- Serum creatinine ≥1.5 mg/dL
Why No Bridging Is Needed
Unlike perioperative warfarin interruption where bridging may be considered for high-risk patients, the transition from warfarin to a direct oral anticoagulant like apixaban does not require bridging therapy 2. The key difference is that apixaban achieves therapeutic anticoagulation promptly after administration, unlike warfarin which requires days to reach therapeutic effect 2.
Monitoring During Transition
- Check INR before starting apixaban to confirm it is below 2.0 1
- No routine coagulation monitoring is required once apixaban is started, as it does not require INR monitoring like warfarin 1
- Assess renal function before initiating apixaban and at least annually thereafter, as renal impairment affects dosing and drug accumulation 2
Common Pitfalls to Avoid
Do not overlap warfarin and apixaban at therapeutic doses, as this significantly increases bleeding risk without added benefit 1. The transition should be sequential, not concurrent.
Do not use heparin bridging during this transition—this outdated practice increases bleeding risk without reducing thrombotic events in this specific scenario 2. Bridging is only relevant when warfarin is being interrupted for procedures, not when transitioning to another oral anticoagulant.
Do not start apixaban while INR is still ≥2.0, as the combined anticoagulant effect increases bleeding risk 1. Wait for the INR to fall below 2.0 naturally (typically 2-3 days after stopping warfarin) 2.
Special Considerations for Renal Impairment
For patients with creatinine clearance 25-30 mL/min, standard apixaban dosing (5 mg twice daily or 2.5 mg twice daily based on dose reduction criteria) appears safe and may cause less bleeding than warfarin 3. However, for patients with creatinine clearance <15 mL/min or on dialysis, warfarin remains the preferred anticoagulant as apixaban lacks clinical trial data in this population 2.