Switching from a VKA to a non-VKA OAC

Discontinue the VKA and start apixaban at INR < 2.0

Discontinue the VKA and start dabigatran at INR < 2.0

Discontinue the VKA and start edoxaban at INR ≤ 2.5

Discontinue the VKA and start rivaroxaban at INR ≤ 3.0 for stroke prevention in patients with non-valvular AF and ≤2.5 for treatment and secondary prevention of VTE

Switching to a VKA from a non-VKA OAC

Continue apixaban for at least 2 days after beginning VKA therapy. After 2 days of co-administration, obtain an INR prior to the next scheduled dose of apixaban, and continue co-administration until the INR is ≥2.0

If CrCl is ≥50 ml/min, start VKA 3 days before discontinuing dabigatran

If CrCl is 30 - 49 ml/min, start VKA 2 days before discontinuing dabigatran

Ensure continuous adequate anticoagulation during any transition to an alternate anticoagulant

Oral option: For patients currently on a 60 mg od or 30 mg od dose, administer edoxaban together with VKA

Patients should not take a loading dose of VKA in order to promptly achieve a stable INR between 2.0 and 3.0. It is recommended to take into account the maintenance dose of VKA and if the patient was previously taking a VKA or to use a valid INR-driven VKA treatment algorithm, in accordance with local practice

Once an INR ≥ 2.0 is achieved, edoxaban should be discontinued. Most patients (85%) should be able to achieve an INR ≥ 2.0 within 14 days of concomitant administration. After 14 days it is recommended that edoxaban is discontinued and the VKA continued to achieve an INR between 2.0 and 3.0

It is recommended that during the first 14 days of concomitant therapy the INR is measured at least three times just prior to taking the daily dose of edoxaban. Concomitant edoxaban and VKA can increase the INR post edoxaban dose by up to 46%

Parenteral option: Discontinue edoxaban and administer a parenteral anticoagulant and VKA at the time of the next scheduled edoxaban dose. Once a stable INR of ≥2.0 is achieved, the parenteral anticoagulant should be discontinued and the VKA continued

Give the VKA and rivaroxaban concurrently until the INR is ≥2.0; standard initial VKA dosing should be given for the first 2 days of the conversion period, followed by INR-guided VKA dosing; INR should not be tested earlier than 24 h after the previous rivaroxaban dose

Switching from a parenteral anticoagulant to a non-VKA OAC

Switch at the next scheduled dose

Stop the parenteral agent and start dabigatran 0 - 2 h prior to the time that the next dose of the parenteral therapy would be due, or at the time of discontinuation in case of continuous treatment (e.g. intravenous UFH)

s.c. anticoagulant (e.g. LMWH, fondaparinux): discontinue s.c. anticoagulant and start edoxaban at the time of the next scheduled s.c. dose

Intravenous UFH: discontinue the infusion and start edoxaban 4 h later

Stop the parenteral agent and start rivaroxaban 0 - 2 h before the time of the next scheduled administration of the parenteral agent (e.g. for LMWH) would be due, or at the time of discontinuation of a continuously administered parenteral medicinal product (e.g. UFH)

Switching to a parenteral anticoagulant from a non-VKA OAC

Switch at the next scheduled dose. These agents should not be administered simultaneously

Wait 12 h after the last dose before switching from dabigatran to a parenteral anticoagulant (non-valvular AF, treatment and secondary prevention of DVT/PE); wait 24 h after the last dose before switching from dabigatran to a parenteral anticoagulant for VTE prevention after major orthopaedic surgery

Discontinue edoxaban and start the parenteral anticoagulant at the time of the next scheduled dose

Give the first dose of parenteral anticoagulant at the time the next rivaroxaban dose would be taken

Switching between non-VKA OACs [56]

Discontinue the current non-VKA OAC and begin the other non-VKA OAC at the next scheduled dose (except in situations in which higher-than-therapeutic plasma concentrations are expected, e.g. in a patient with impaired renal function)