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Madeleine Turcotte

Agent Treatment Dose Renal Dose Prophylaxis Monitoring
Unfractionated heparin 80 U/kg bolus, then 18 U/kg/hr No change necessary 5000 U q8h PTT (automatic in order set)



1 mg/kg q12h 1 mg/kg daily

40 mg daily


30 mg BID

LMWH level (anti-Xa level)

Best checked 4 h after 4th dose


Warfarin (Coumadin)

Start 2-5mg daily and monitor INR

Can consult Pharmacy


No change




Use Chromogenic Factor X assay if pt has APLS

Dabigatran (Pradaxa)

After 5 days of a parenteral AC,

150 mg BID

Avoid use N/A

Can test drug level if concerned

(Any DOAC)

Rivaroxaban (Xarelto) 15 mg BID x21 d then 20 mg daily Avoid use in CrCl<30 10mg QD  
Apixaban (Eliquis) 10mg BID x7d, then 5mg BID VTE: No adjustment 2.5 mg BID

A Fib:

2.5mg BID, if 2 of the following:

Cr 1.5, Age > 80

Weight < 60kg

Edoxaban (Savaysa)

After 5 days of a parenteral AC,

60 mg daily

30 mg for

CrCl 15-50

Avoid if CrCl > 95

  Best studied option in renal dysfunction

Additional Information

  • VA is starting to move towards rivaroxaban and apixaban for extended secondary thromboprophylaxis
    • Write in your PADR for apixaban citing “patient uses a pillbox and cannot use dabigatran”
  • Renal dysfunction: favor warfarin, apixaban or edoxaban
  • Hx of GI bleed: avoid dabigatran, rivaroxaban, edoxaban (may have higher risk of GI bleed)
  • Pregnancy: UFH/LMWH (other agents may cross the placenta)

Transitioning Between Anticoagulants with DOACs

  • LMWH to Warfarin
    • Warfarin and LMWH given simultaneously until INR is therapeutic for 24 hours
  • Warfarin to DOAC
    • Start DOAC when INR < 2.0
  • DOAC to Warfarin
    • High Risk DVT/PE – start LMWH or UFH, then start Warfarin
    • Low to Moderate Risk DVT/PE – Start warfarin while patient on DOAC, Stop DOAC on Day 3 of warfarin therapy, Check INR on day 4
  • LMWH to DOAC
    • Stop LMWH and start DOAC when due for next dose of LMWH (within 2 hrs)
  • DOAC to LMWH
    • Stop DOAC and start LMWH when due for next DOAC dose
  • UFH to DOAC
    • Start DOAC when IV stopped (30 min prior to cessation if high risk for thrombosis)
  • DOAC to UFH
    • Start IV heparin with bolus when next DOAC dose is due

Peri-Procedural Management of Anticoagulation

  • Temporary IVC filter indicated in pts with very recent acute VTE (within 3-4 weeks) if the procedure requires AC delay >12 hours
  • For those at high risk of thromboembolism:
    • Consider continuing AC for low-bleeding-risk procedures, i.e. dental procedures, cutaneous biopsy/excision, ICD placement, endovascular procedures.
    • Can bridge with LMWH or heparin drip
Stop before procedure Restart after procedure
Warfarin 5 days prior, check INR day of 12 to 24 hours after

48 hours prior

(longer if CrCl 30-50 or procedure is high bleeding risk)

1 day after

(2 days if high bleeding risk)

Heparin Stop infusion 4-5 hours prior 24 hours after
Enoxaparin 12 - 24 hours prior 24 hours after, (48-72 hours if high bleeding risk)

Strategies for Reversal of Anticoagulation


  • Vitamin K: onset within a few hours but takes 24-48 hrs for full effect
  • Life Threatening Bleeding: Give IV Vitamin K 10 mg over 30 minutes
  • Intracranial bleed, bleed with hemodynamic instability, emergent procedure non-life threatening
    • INR <5: Vitamin K not recommended
    • INR 5-10: Vitamin K 1-5 mg IV or PO
    • INR >10: Vitamin K 5mg PO or 5 mg IV
  • Prior to surgery
    • Rapid reversal INR > 5: 5mg Vit K IV (24 hours prior to procedure)
  • FFP
    • 15 ml/kg (i.e. 4 units/70 kg person) if need reversal <24 hrs, plus give Vitamin K
  • KCentra ($$$): Contains Factors II, VII, IX, and X with Protein C, Protein S, and heparin
    • Given instead of plasma when insufficient time for plasma/Vit K to work (i.e. for life threatening hemorrhage)
    • Avoid giving this in HIT
    • Administer with Vitamin K


  • Idarucizumab ($$$) will reverse if prolonged thrombin time (remember to check!) – Consult Hematology

Factor Xa Inhibitors (rivaroxaban, apixaban, edoxaban)

  • FEIBA (Factor VIII inhibitor bypassing activity) – can promote coagulation but is not a reversal agent; limited data to support use
  • Consult Hematology before using; andexanet alfa (FDA approved) is not on VUMC formulary but is on the VA formulary

Last update: 2022-06-24 23:35:57