During transition from a DOAC to warfarin, which approach may be used to manage INR during the transition?

During transition from a DOAC to warfarin, which approach may be used to manage INR during the transition?

• A. Overlap with DOAC or injectable until INR is within range
• B. Continue DOAC until INR is therapeutic, but watch INR elevation
• C. Stop DOAC immediately and start warfarin
• D. Do not monitor INR during transition

Answer: (A)

When switching from a DOAC to warfarin, you must maintain anticoagulation during the transition because warfarin takes several days to reach a therapeutic effect. The safest approach is to overlap warfarin with either the DOAC or with a parenteral anticoagulant (like LMWH or UFH) until the INR is in the target range and stable. Once the INR is therapeutic, you can discontinue the DOAC (or the parenteral agent) and continue warfarin alone. This overlap prevents gaps in protection that could allow thrombosis while warfarin is titrated. Stopping the DOAC abruptly would create a period without adequate anticoagulation. Relying on the INR to guide the transition while the DOAC is still active is unreliable, since DOACs do not consistently affect INR and can complicate assessment. Not monitoring INR during the transition is unsafe because adjusting warfarin dosing depends on accurate INR measurements.

When switching from a DOAC to warfarin, you must maintain anticoagulation during the transition because warfarin takes several days to reach a therapeutic effect. The safest approach is to overlap warfarin with either the DOAC or with a parenteral anticoagulant (like LMWH or UFH) until the INR is in the target range and stable. Once the INR is therapeutic, you can discontinue the DOAC (or the parenteral agent) and continue warfarin alone. This overlap prevents gaps in protection that could allow thrombosis while warfarin is titrated.

Stopping the DOAC abruptly would create a period without adequate anticoagulation. Relying on the INR to guide the transition while the DOAC is still active is unreliable, since DOACs do not consistently affect INR and can complicate assessment. Not monitoring INR during the transition is unsafe because adjusting warfarin dosing depends on accurate INR measurements.