Discontinue rivaroxaban and begin a parenteral anticoagulant if indicated and warfarin at the time the next scheduled rivaroxaban dose would have been taken. Continue parenteral anticoagulant until the desired INR is reached.
OR
Commence warfarin in combination with rivaroxaban. Rivaroxaban should be discontinued when INR is in therapeutic range. Measure INR prior to each dose of rivaroxaban being administered.
Notably, warfarin shouldn’t be started without a period of coadministration with another anticoagulant. Patients in the ROCKET-AF trial who were switched from Xarelto to warfarin without a period of bridging/coadministration had higher rates of stroke than those maintained on warfarin.
References:
1) Uptodate [online]: Rivaroxaban: Drug information
2) 2017 AHA Scientific Statement: “Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting”
3) https://www.gwh.nhs.uk/media/236485/doac-switch-guidance-oct-2016.pdf
[All accessed on 23 October 2018]
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