Warfarin

Stop warfarin. 
Start edoxaban when INR is less than or equal to 2.5.

For stroke and systemic embolism prophylaxis stop warfarin and initiate rivaroxaban when INR is less than or equal to 3·0. For patients treated for DVT, PE and prevention of recurrence, stop warfarin and initiate rivaroxaban once INR is less than or equal to 2·5.

Stop warfarin. Dabigatran can be given as soon as INR is less than 2·0.
Patient must be able to swallow capsule whole, as opening or chewing the capsule increases oral bioavailability and bleeding risk.

Stop warfarin. Start apixaban when INR is less than 2·0.

Stop warfarin therapy. Give first dose of parenteral
anticoagulant when INR is less than 2·0.

Edoxaban

For patients on edoxaban 60mg daily, give edoxaban 30mg once daily with standard initial dosing of warfarin. For patients on edoxaban 30mg daily, give edoxaban 15mg once daily with standard initial dosing of warfarin.

While patients are on both edoxaban and warfarin measure INR at least 3 times during first 14 days of concomitant therapy just before the daily dose of edoxaban. Continue co-administration of edoxaban and warfarin until INR is greater than or equal to 2·0.

Stop edoxaban and start rivaroxaban at the time the next dose of edoxaban would have been due.

Stop edoxaban and start dabigatran at the time the next dose of edoxaban would have been due.

Stop edoxaban and start apixaban at the time the next dose of edoxaban would have been due.

Discontinue edoxaban and start parenteral anticoagulant at the time the next dose of edoxaban would have been due.

These agents should not be administered together.

Rivaroxaban

Give warfarin concurrently until INR is greater than, or equal to 2·0 for 2 days. For the first 2 days use standard initial dosing of warfarin, followed by warfarin dosing guided by INR testing. While patients are on both rivaroxaban and warfarin test INR just prior to the next dose of rivaroxaban.

Stop rivaroxaban.
Start edoxaban at the time the next dose of rivaroxaban would have been due.

Stop rivaroxaban. Start dabigatran 24 hours after the last dose of rivaroxaban.

Stop rivaroxaban. Start apixaban at the time the next rivaroxaban dose would have been due.

Stop rivaroxaban. Start the first dose of parenteral anticoagulant at the time the next rivaroxaban dose would be due. These agents must not be administered together.

Dabigatran

Adjust the starting time of the warfarin based on CrCL:

• CrCL greater than or equal to 50 mL/min, start warfarin 3 days before stopping dabigatran.
• CrCL 30 to 49 mL/min, start warfarin 2 days before stopping dabigatran.

INR testing is unreliable until dabigatran has been stopped for at least 2 days.

Stop dabigatran.
Start edoxaban at the time the next dose of dabigatran would have been due.

• If CrCL greater than or equal to 50mL/min start rivaroxaban 24 hours after last dose of dabigatran.
• If CrCL 30 to 49mL/min start rivaroxaban 48 hours after last dose of dabigatran.
• If CrCL less than 30mL/min commence rivaroxaban 3 to 4 days after last dose of dabigatran.

Stop dabigatran. Start apixaban at the time the next dabigatran dose would have been due.

It is recommended to wait at least 12 hours after the last dose before switching from dabigatran to parenteral anticoagulant.

Apixiban

Give warfarin concurrently using standard initial dosing for at least 2 days. After 2 days of co-administration obtain INR prior to next dose of apixaban. Continue co-administration of apixaban and warfarin until INR is greater than or equal to 2·0.

Stop apixaban.
Start edoxaban at the time the next dose of apixaban would have been due.

Stop apixaban. Start rivaroxaban when the next dose of apixaban would have been due.

Stop apixaban. Start
dabigatran at the time the next apixaban dose would have been due.

Stop apixaban. Start parenteral anticoagulant at the time the next dose of apixaban would have been due. These agents should not be administered together.

Parenteral anticoagulants

Continue parenteral anticoagulant for at least 5 days and until the INR is above the lower limit of the desired therapeutic range for 24 hours, ie 2 INRs 24 hours apart.

Stop the parenteral anticoagulant immediately if INR is greater than the upper limit of the desired therapeutic range.

Stop subcutaneous LMWH or fondaparinux and start edoxaban at the time of the next scheduled dose of subcutaneous LMWH or fondaparinux.

Stop UH infusion and start edoxaban 4 hours later.

Start rivaroxaban 0 to 2 hours before the time of the next scheduled dose of LMWH or fondaparinux or at the same time of discontinuation of a continuous infusion of UH**.

Start dabigatran 0 to 2 hours before the time of the next scheduled dose of LMWH or fondaparinux or at the same time of discontinuation of a continuous infusion of UH**.

Start apixaban at the next scheduled dose of LMWH or fondaparinux or at the same time of discontinuation of a continuous infusion of UH**.