Mount Carmel Health Partners Clinical Guidelines Atrial Fibrillation | Page 7

Anticoagulants
Medication Dosage Contraindications and Potential
Adverse Drug Reactions (ADRs) Special Considerations and Monitoring
Apixaban(Eliquis)
Factor Xa Inhibitor 5 mg, twice daily (2.5
mg, twice daily if two
of these factors: age
>80, weight <60 kg or
sCR >1.5 m/dL) Contraindications: Do not use in severe
liver disease; do not use in patients on
dialysis if CrCl <15
Drug-drug interactions with azole, HIV
protease inhibitors, macrolide
antibiotics, carbamazepine, phenytoin,
rifampin Only NOAC with proven survival benefit
against warfarin; lower bleeding risk than
aspirin
Activated charcoal may be useful in
managing overdose or accidental ingestion
Dabigatr an (Pradaxa)
Direct thrombin
inhibitor 150 mg, twice daily;
75 mg, twice daily for
CrCl 15-30; use caution
in this class due to lack
of studies Contraindication: Do not use if
CrCl <30 ml/min
ADR: dyspepsia, GI side effects, increased
GI bleeds
Drug-drug interactions with antacids,
verapamil, amiodarone, clarithromycin,
rifampin, carbamezapine Rivaroxaban (Xarelto)
Factor Xa inhibitor 20 mg, once daily
(15 mg, daily if CrCL is
15-50) taken with
evening meal Contraindication: Do not use in liver
disease or if CrCL <15;
Drug-drug interactions with azoles,
carbamazepine, HIV protease inhibitors,
macrolide antibiotics, phenytoin,
primidone, rifampin, phenobarbitol Warfarin (Coumadin)
Vitamin K antagonist Dose based on
current and previous
INRs Many drug-drug and food-drug
interactions 60 mg, daily
CrCl 15-50, 30 mg daily CrCl >95 avoid use; CrCl <15 avoid use
Edoxaban (Savaysa)
Factor Xa inhibitor
Caution with use of 75 mg dose in renal
impairment, as this dose has never been
studied; must remain in original packaging
Antidote: Idarucizumab (Praxbind)
Once daily dosing and less GI effects make
this the preferred NOAC for some patients
Monitoring: INR tests at least every 4 weeks,
frequency based on INR level
Antidote: vitamin K, fresh frozen plasma
Switch between anticoagulants wisely (continued):
Rivaroxaban → Warfarin
• Start warfarin while patient is still taking rivaroxaban. Stop
rivaroxaban 2 to 4 days later with timing based on patient’s
creatinine clearance (CrCl) and INR level
• If CrCl is >50: check INR on day 4 of overlap
▫ if INR is ≥2, stop rivaroxaban, repeat INR after 1 to 2 days
of warfarin alone
▫ if INR <2.0, consider continuing rivaroxaban along with
warfarin; repeat INR 1 to 2 days later
• If CrCl = 31-50: stop rivaroxaban 3 days later and check INR
after 1 to 2 days of warfarin alone
• If CrCl <30: stop rivaroxaban 2 days later and check INR after
2 days on warfarin alone
Edoxaban → Warfarin
· If on 60mg dose, reduce to 30mg daily and start warfarin.
· If on 30mg dose, reduce to 15mg daily and start warfarin. Check
INR at least weekly and stop edoxaban once INR greater than
or equal to 2
Premature discontinuation increases risk for
ischemic events.
Enoxaparin → NOAC
• Stop enoxaparin and start dabigatran, rivaroxaban,
apixaban, or edoxaban at usual time of next scheduled
dose of enoxaparin.
NOAC → IV UH or LMWH
• Apixaban: start unfractionated heparin or low
molecular-weight heparin 12 hours after last apixaban
dose
• Dabigatran:
▫ If CrCl >30: start unfractionated heparin or low
molecular-weight heparin 12 hours after last
dabigatran dose
▫ If CrCl <30: consider LMWH 24 hours after last
dabigatran dose based on clinical interpretation of
the patient’s risk of bleeding and thrombosis
• Rivaroxaban: start unfractionated heparin or LMWH 12
hours after last rivaroxaban dose if patient is within first
21 days of treatment for VTE or 24 hours after last
rivaroxaban dose for other indications
Initiate warfarin wisely:
• Consider warfarin sensitivity. Lower initiation dose for patients with the following: age >75 years, congestive heart failure,
diarrhea, drug interactions, elevated baseline INR, fever, hyperthyroidism, malignancy, malnutrition, or NPO greater than 3 days.
• Check INR frequently during titration. Obtain INR 3 days after the first starting dose, then every 2 to 3 days until in-range INR is
achieved on two measurements. Check the INR one week after the second in-range INR.
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