--- title: "Conversions to and from other anticoagulants" canonical: "https://clinicaldecisions.refined.site/space/Haematology/31785469/Conversions+to+and+from+other+anticoagulants" format: markdown --- ### Conversion to Dabigatran | | | | --- | --- | | ### Agent | ### Conversion Instructions | | Heparin | Start dabigatran at the time the heparin infusion is turned off. | | Enoxaparin | Start dabigatran at the time the next dose of enoxaparin was to be administered (may overlap by up to 2 hours). If enoxaparin was adjusted for renal function, dabigatran may also require dose adjustment (see Table for [Atrial Fibrillation dosing](https://clinicaldecisions.atlassian.net/wiki/spaces/Haematology/pages/31687148)) | | Warfarin | Discontinue warfarin and start dabigatran when the INR is <2.0. | ### CONVERSION FROM DABIGATRAN The following recommendations are based on the approved labeling for the use of dabigatran in patients with atrial fibrillation. Considering the risk of stroke and embolism in each patient (ie, CHADS2 score, cardioversion), it may be reasonable to continue dabigatran until the INR is 2-3. These guidelines do not reflect the practice of overlapping parenteral anticoagulants and warfarin for 5 days in the treatment of pulmonary embolism (PE) or deep vein thrombosis (DVT). Dabigatran is NOT approved at this time for the treatment of PE or DVT. Overlapping beyond the number of days recommended below may be considered on an individual basis assessing the risk of embolism and bleeding. (Jaff M. Circulation. 2011;123:00.) ### Converting Dabigatran to Warfarin | | | | --- | --- | | ### **Renal Function** (CrCL mL/min) | ### Conversion Instructions^a | | >50 | Start warfarin and overlap with dabigatran for 3 days. Discontinue dabigatran on day 4. | | 31-50 | Start warfarin and overlap for 2 days with dabigatran. Discontinue dabigatran on day 3. | | 15-30 | Start warfarin and overlap for 1 day with dabigatran. Discontinue dabigatran on day 2. | | <15 | Start warfarin and overlap for 1 day with dabigatran. Discontinue dabigatran on day 2. This patient should not resume dabigatran therapy.^b | | ^**a** Dabigatran may contribute to an elevated INR for up to 2 days after discontinuation. ^b No data exist in patients with CrCL < 15 mL/min or in patients on haemodialysis. Recommendations are extrapolated from pharmacokinetic data and comparison of relative risks and benefits. | ### Converting Dabigatran to Parenteral Anticoagulants (Heparin, Enoxaparin) | | | | --- | --- | | ### **Renal Function** (CrCL mL/min) | ### Conversion Instructions^a | | ≥ 30 | Start parenteral anticoagulant 12 hours after last dabigatran dose. | | < 30 | Start parenteral anticoagulant 24 hours after last dabigatran dose. | | ^**a** Methods for converting dabigatran to heparin have not been studied and are based on the pharmacokinetics of the drug. Clinical decisions should be made based on patient-specific risk of bleeding vs. thromboembolism. | --- Reviewed September 2024 [REVIEW DUE] [Send feedback](https://clinicaldecisionsupport.atlassian.net/wiki/spaces/HAEMATOLOGY/pages/881131740/Page+coordinators+Haematology) to page coordinator