Suggestions for Conversion To/From Dabigatran

CONVERSION UW MEDICINE RECOMMENDATION
From warfarin to dabigatran Stop warfarin and start dabigatran when INR < lower limit of therapeutic range

From dabigatran to warfarin

 

(NOTE: dabigatran is not intended to be used as a short term "bridge" to warfarin.  These recommendations refer to transitioning patients who are taking dabigatran on a long term basis and are switching to warfarin instead)

 

 

Clcr > 50 mL/min:   start warfarin and stop dabigatran 3 days later
Clcr 31-50 mL/min: start warfarin and stop dabigatran 2 days later
Clcr 15-30 mL/min: start warfarin and stop dabigatran 1 day later
(dabigatran may alter INR results; therefore, using INR to guide when to stop dabigatran is not reliable)
From LMWH/ fondaparinux to dabigatran Stop  parenteral anticoagulant and administer dabigatran 0-2 hours before next parenteral dose would have been given
From IV heparin to dabigatran Administer first dose of dabigatran at time of discontinuation of IV heparin infusion
From dabigatran to parenteral anticoagulant Clcr > 30 mL/min:  Start parenteral anticoagulant 12 hours after the
last dose of dabigatran
Clcr < 30 mL/min:  Start parenteral anticoagulant 24 hours after  the
last dose of dabigatran
From dabigatran to apixaban, exoxaban or rivaroxaban   stop dabigatran and begin the other agent at the time that the next dose of dabigatran would have been given