From the Guidelines
Yes, you can bridge a patient from Eliquis (apixaban) to warfarin, and the recommended approach is to start warfarin while continuing Eliquis for at least 2 days, then check the INR daily while the patient is on both medications, as supported by the 2024 AHA/ACC guideline 1. The decision to bridge a patient from Eliquis to warfarin should be based on the individual patient's risk of thromboembolism and bleeding, as well as their specific clinical circumstances, such as the presence of atrial fibrillation or mechanical heart valves, as outlined in the 2021 ACC/AHA clinical performance and quality measures for adults with atrial fibrillation or atrial flutter 1. Some key points to consider when bridging a patient from Eliquis to warfarin include:
- Starting warfarin while the patient is still taking Eliquis to ensure continuous anticoagulation protection, as recommended in the 2024 AHA/ACC guideline 1
- Checking the INR daily while the patient is on both medications to determine when the warfarin has reached therapeutic effect, as suggested in the 2021 ACC/AHA clinical performance and quality measures 1
- Discontinuing Eliquis once the INR reaches the target range, typically 2.0-3.0 for most indications, as stated in the 2024 AHA/ACC guideline 1
- Considering the patient's renal function and other comorbidities when determining the duration of overlap, as outlined in the 2024 AHA/ACC guideline 1
- Using a team-based approach to decision-making, especially in high thrombotic risk patients or when undergoing procedures with higher risks of adverse outcome, should bleeding occur, as recommended in the 2024 AHA/ACC guideline 1 It's also important to note that the 2021 ACC/AHA clinical performance and quality measures recommend using the CHA2DS2-VASc score to assess stroke risk in patients with atrial fibrillation, and that the selection of anticoagulant therapy should be based on the risk of thromboembolism, irrespective of whether the AF pattern is paroxysmal, persistent, or permanent 1.
From the FDA Drug Label
Switching from apixaban to warfarin: apixaban affects INR, so that initial INR measurements during the transition to warfarin may not be useful for determining the appropriate dose of warfarin One approach is to discontinue apixaban and begin both a parenteral anticoagulant and warfarin at the time the next dose of apixaban would have been taken, discontinuing the parenteral anticoagulant when INR reaches an acceptable range
Bridging with Eliquis (apixaban) to warfarin is not directly supported by the label. However, the label does provide guidance on switching from apixaban to warfarin, which involves discontinuing apixaban and starting both a parenteral anticoagulant and warfarin. The parenteral anticoagulant can be discontinued when the INR reaches an acceptable range 2.
From the Research
Bridging Patients from Eliquis to Warfarin
- The provided studies do not directly address bridging patients from Eliquis (apixaban) to warfarin.
- However, the studies compare the safety and efficacy of apixaban versus warfarin in various patient populations, including those with end-stage renal disease, atrial fibrillation, and venous thromboembolism 3, 4, 5, 6, 7.
- Apixaban is generally associated with a lower risk of major bleeding, intracranial bleeding, and gastrointestinal bleeding compared to warfarin 3, 5, 7.
- The decision to bridge a patient from apixaban to warfarin should be based on individual patient factors and clinical judgment, as there is no direct evidence to support a specific bridging strategy.
Considerations for Bridging
- When transitioning a patient from apixaban to warfarin, it is essential to consider the patient's underlying condition, renal function, and bleeding risk 3, 5.
- The studies suggest that apixaban may be a safer alternative to warfarin in certain patient populations, such as those with end-stage renal disease or obesity 3, 5, 7.
- However, the lack of direct evidence on bridging strategies highlights the need for further research and clinical guidance on this topic.