switching from DOACs to warfarin

[qtern]

Hi, I was wondering when you switch from DOACs (like xarelto,eliquis) to warfarin, why do you have to bridge with LMWH? isn't keeping the patient on both for a few days until warfarin become therapeutic is enough? Or is it too dangerous to be on both, even for a few days? Please help me clarify. Many thanks!

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[mfdoom]

DOACs can affect INR, so the reading might be falsely elevated if you are taking both a DOAC and warfarin. In practice, I've seen some people bridge and some people don't.

 

[CetiAlphaFive]

Look up the differences in the enantiomers.

 

[qtern]

DOACs can affect INR, so the reading might be falsely elevated if you are taking both a DOAC and warfarin. In practice, I've seen some people bridge and some people don't.

Many thanks! Do you see anybody bridge when switching from Pradaxa? it seems like this is the only one that does not explicitly mention the need for bridging.

 

[PharmDBro2017]

DOACs can affect INR, so the reading might be falsely elevated if you are taking both a DOAC and warfarin. In practice, I've seen some people bridge and some people don't.

What about false INR elevation from solely a DOAC (Xarelto, pt not also on warfarin)? Does that occur?

Had a pt with INR ~8 recently, physician wanted to give 10mg IV Vit K with no active signs of bleeding.

 

[Dred Pirate]

What about false INR elevation from solely a DOAC (Xarelto, pt not also on warfarin)? Does that occur?

Had a pt with INR ~8 recently, physician wanted to give 10mg IV Vit K with no active signs of bleeding.

yes it does - and no, you should not give reversal agents to someone with an elevated INR on a DOAC with no signs of bleeding, I have probably had that conversation a dozen times with docs

 

[mfdoom]

yes it does - and no, you should not give reversal agents to someone with an elevated INR on a DOAC with no signs of bleeding, I have probably had that conversation a dozen times with docs

I've read over and over again that common coag assays are not good measures of DOACs but they still make me paranoid (like super high aPTT on a dabigatran pt). Dat warfarin brainwashing, man.

 

[mfdoom]

Many thanks! Do you see anybody bridge when switching from Pradaxa? it seems like this is the only one that does not explicitly mention the need for bridging.

I've never seen anyone transition from dabigatran to warfarin. Looks like the package insert has its own recommendations, though. Makes it easier.

 

[Dred Pirate]

I've read over and over again that common coag assays are not good measures of DOACs but they still make me paranoid (like super high aPTT on a dabigatran pt). Dat warfarin brainwashing, man.

agreed - I had one doc ask me 5 times -"do the INR is 6, I don't need to do anything? I leave him on it?" After 4 times I said, "do you want me to call my coag expert?" a "Will ya?" - 3 minutes later, "nope - just keep going"

 

[ldiot]

Only use Vitamin K if INR>10, or if there are signs of bleeding with an INR 4.5-10.

Bridging is recommended when going from a DOAC to warfarin, but you don't have to give lovenox or LMWH. You just keep them on the DOAC while starting warfarin.

For Apixaban:
Start warfarin and overlap for at least 5 days. D/C apixaban on day 5 or when INR>2 (whichever is longer)

For Edoxaban:
Cut the dose of edoxaban in half when initiating warfarin, and d/c edoxaban when INR is both stable and >2

Rivaroxaban:
Start warfarin and overlap for at least 3 days. D/C rivaroxaban on day 3 or when INR>2 (whichever is longer)

Dabigatran:
CrCl >50 overlap for 3 days
CrCl 31-50 overlap for 2 days
CrCl 15-30 overlap for 1 day

 

[Dred Pirate]

Only use Vitamin K if INR>10, or if there are signs of bleeding with an INR 4.5-10.

\

Not sure if you realize, but the question was a little off topic - the questions was "what do you do with an elevated INR on a DOAC" - your answer is what you do with an elevated INR on warfarin - do not give vitamin k for an elevated INR on a DOAC - it means NOTHING, only give if the pt is bleeding, actually you should never drawn INR on a patient on a doac for that very reason

 

[ldiot]

Not sure if you realize, but the question was a little off topic - the questions was "what do you do with an elevated INR on a DOAC" - your answer is what you do with an elevated INR on warfarin - do not give vitamin k for an elevated INR on a DOAC - it means NOTHING, only give if the pt is bleeding, actually you should never drawn INR on a patient on a doac for that very reason

Oh yeah I was referring to warfarin monotherapy.

 

[CetiAlphaFive]

Only use Vitamin K if INR>10, or if there are signs of bleeding with an INR 4.5-10
Bridging is recommended when going from a DOAC to warfarin, but you don't have to give lovenox or LMWH. You just keep them on the DOAC while starting warfarin.
For Apixaban:
Start warfarin and overlap for at least 5 days. D/C apixaban on day 5 or when INR>2 (whichever is longer)
For Edoxaban:
Cut the dose of edoxaban in half when initiating warfarin, and d/c edoxaban when INR is both stable and >2
Rivaroxaban:
Start warfarin and overlap for at least 3 days. D/C rivaroxaban on day 3 or when INR>2 (whichever is longer)
Dabigatran:
CrCl >50 overlap for 3 days
CrCl 31-50 overlap for 2 days
CrCl 15-30 overlap for 1 day

I once had a patient who should've been on hospice who I knew really well.

Poor guy was very hypoxic and non-compliant. He wouldn't listen to any advice or do what he needed to.

His family thought he was a drug addict because he'd take 2 Norco 5/325mg a day.

So, one day ***** McDumbass, RN comes to stay with him and "fix" the patient's problems.

She would come into the pharmacy and explain how she'd been an RN for 37 years so she knew better than us and the MD.
Basically causing a ruckus and being a pain in the ass.

One day she calls us and starts chewing me out because he's run out of one of his medicines.
She *demands* to know why we haven't given him his Mephyton when she's been making sure to put it in his med-planner everyday for the two weeks she's been in town.

My heart stopped for a minute until she described them as fruit shaped gummies.
Pt. Had filled his old Rx bottle with gummies vitamins for some crazy reason.

 

[Chriskahn]

Only use Vitamin K if INR>10, or if there are signs of bleeding with an INR 4.5-10

The warfarin protocol at the hospital I'm rotating at says to give Vitamin K when INR > 4.5 or any INR if there is active bleeding

 

[PharmDBro2017]

yes it does - and no, you should not give reversal agents to someone with an elevated INR on a DOAC with no signs of bleeding, I have probably had that conversation a dozen times with docs

Exactly... I had to argue that it was incorrect to give vit K cuz pt had no signs or symptoms or active bleeding.


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[Dred Pirate]

The warfarin protocol at the hospital I'm rotating at says to give Vitamin K when INR > 4.5 or any INR if there is active bleeding

personally I think that is a bad protocol.

But to clarify - do you mean IV or po? I would not give vitamin k without bleeding until the INR was at least 8. If it is 4.5 and not bleeding, vitamin k does more harm that good - you end up getting warfarin resistent and stuck with subtherapeutic INR and risk for clot

 

[CetiAlphaFive]

Always be the patient advocate, even when they're a *****.

Tucson woman wins $12 million jury verdict against Banner-UMC in malpractice case