| To From |
UFH (IV) | Enoxaparin Therapeutic BD dose SC | Apixaban | Rivaroxaban | Dabigatran | Warfarin |
|---|---|---|---|---|---|---|
| UFH (IV) | Stop UFH and start enoxaparin at the same time | Stop UFH and start apixaban at the same time | Stop UFH and start rivaroxaban at the same time | Stop UFH and start dagibatran at the same time | Start warfarin and UFH concurrently. Continue UFH for a Min. 5/7 & until INR in therapeutic range for 2 consecutive days | |
| Enoxaparin therapeutic BD dose SC | Stop enoxaparin and start IV UFH 1-2 hours before the next dose of enoxaparin would have been given | Stop enoxaparin and give 1st dose of apixaban at the time the next dose of enoxaparin would have been given | Stop enoxaparin and give 1st dose of rivaroxaban at the time the next dose of enoxaparin would have been given | Stop enoxaparin and give 1st dose of dabigatran at the time the next dose of enoxaparin would have been given | Start warfarin and enoxaparin concurrently. Continue enoxaparin for a minimum of 5 days and until INR is in therapeutic range for two consecutive tests | |
| Enoxaparin Therapeutic OD dose SC | Stop enoxaparin and start UFH 1-2 hours before the next dose of enoxaparin would have been given | Give next dose of enoxaparin 12 hours after the last dose was given | Stop enoxaparin and give first dose of apixaban at the time the next dose of enoxaparin would have been given | Stop enoxaparin and give first dose of rivaroxaban at the time the next dose of enoxaparin would have been given | Stop enoxaparin and give first dose of dabigatran at the time the next dose of enoxaparin would have been given | Start warfarin and enoxaparin concurrently. Continue enoxaparin for min. 5/7 and INR is in therapeutic range for two consecutive days |
| Apixaban | Stop apixaban and start UFH at the time the next dose of apixaban would have been given | Stop apixaban and give first dose of enoxaparin at the time the next dose of apixaban would have been given | Stop apixaban and give first dose of rivaroxaban at the time the next dose of apixaban would have been given | Stop apixaban and give first dose of dabigatran at the time the next dose of apixaban would have been given | Start warfarin in combination with apixaban. Continue apixaban for 2/7, then check INR prior to each dose of apixaban. Stop apixaban when INR is ≥ 2.0. | |
| Rivaroxaban | Stop rivaroxaban and start UFH at the time the next dose of rivaroxaban would have been given | Stop rivaroxaban and give first dose of enoxaparin at the time the next dose of rivaroxaban would have been given | Stop rivaroxaban and give first dose of apixaban at the time the next dose of rivaroxaban would have been given | Stop rivaroxaban and give first dose of dabigatran at the time the next dose of rivaroxaban would have been given | Start warfarin in combination with rivaroxaban. Rivaroxaban should be discontinued when INR >2. Check INR prior to each dose of rivaroxaban | |
| Dabigatran | Stop dabigatran and start UFH at the time the next dose of dabigatran would have been given | Stop dabigatran and give first dose of enoxaparin at the time the next dose of dabigatran would have been given | Stop dabigatran and give first dose of apixaban at the time the next dose of dabigatran would have been given | Stop dabigatran and give first dose of rivaroxaban at the time the next dose of dabigatran would have been given | If CrCl ≥ 50ml/min.: start warfarin 3/7 before stopping dabigatran. If CrCl 30-50ml/minute: start warfarin 2/7 before stopping dabigatran | |
| Warfarin | Stop warfarin. Start UFH once INR < target range | Stop warfarin. Start enoxaparin once INR < target range | Stop warfarin. Start apixaban when INR <2.0 | DVT, PE Mx and Prev.: stop warfarin & start rivaroxaban when INR ≤2.5. Stroke Prev.: stop warfarin & start rivaroxaban when INR ≤3.0. |
Stop warfarin. Start dabigatran when INR <2 |