to Warfarin

• N/A

to Heparin (CI)

• Stop Warfarin
• Start CI
• Heparin without a bolus when INR <2

to LMWH

• Stop Warfarin
• Start LMWH when INR <2

to Dabigatran

• Stop Warfarin
• Start Dabigatran when INR <2

to Apixaban

• Stop Warfarin
• Start Apixaban when INR <2

to Rivaroxaban

• Stop Warfarin
• Start Rivaroxaban when INR <3

to Edoxoban

• Stop Warfarin
• Start Edoxoban when INR ≤2.5

*Note: Dabigatran, Rivaroxaban, Edoxaban, and Apixaban affect the INR; measuring the INR during coadministration with warfarin therapy may not be useful for determining an appropriate dose of warfarin. To minimize this effect, check INR at trough level of respective medication