Comparison of Managing Factor Xa Inhibitor to Unfractionated Heparin Transitions by aPTT Versus a Treatment Guideline Utilizing Heparin Anti-Xa Levels.

Background: There are inadequate data on the optimal strategy for transitioning factor Xa inhibitors (FXai; apixaban, rivaroxaban) to unfractionated heparin (UFH) infusions.

Objective: In patients transitioning from an FXai to an UFH infusion, this study compared the safety and efficacy of monitoring UFH infusions using an activated partial thromboplastin time (aPTT) titration scale versus utilizing an UFH-calibrated anti-Xa titration scale aided by a novel institutional guideline.

Methods: A retrospective cohort analysis was conducted on adult patients transitioning from an FXai to an UFH infusion at 2 medical centers from June 1, 2018, to November 1, 2020.

Utilization of apixaban anti-Xa levels in transition from apixaban to warfarin in a patient with chronic renal dysfunction.

Purpose: The effect of apixaban on anti-factor Xa (anti-Xa) assays and international normalized ratio (INR) complicates transitions between anticoagulant agents. When switching from apixaban to warfarin, the recommendation is to begin both a parenteral anticoagulant and warfarin at the time of the next apixaban dose and to discontinue the parenteral agent when the INR is in an acceptable range. This proves challenging in renal dysfunction, as continued presence of apixaban contributes to both a prolonged effect on the INR and continued therapeutic levels of anticoagulation.

Use of specific anti-Xa levels in acute kidney injury to transition patients from oral factor Xa inhibitors to i.v. heparin infusion.

Purpose: This case series presents 3 patients with acute kidney injury taking apixaban or rivaroxaban and transitioning to a heparin infusion.

Summary: Case 1 was a 78-year-old man admitted with respiratory failure, acute decompensated heart failure, and acute kidney injury. He was taking apixaban for atrial flutter.

Successful use of laboratory monitoring to facilitate an invasive procedure for a patient treated with dabigatran.

Purpose: A case in which novel and traditional laboratory markers were successfully used to determine surgical intervention timing in an elderly patient receiving dabigatran for atrial fibrillation is reported.

Summary: An 86-year-old woman who was taking dabigatran for atrial fibrillation suffered a right femoral neck fracture requiring surgical intervention. Dabigatran was withheld once the patient was admitted to the hospital, and the pharmacy inpatient anticoagulation management team was consulted for guidance on determining appropriate scheduling of surgical intervention with regard to the time since her most recent dabigatran dose to minimize bleeding complications.