Switching from warfarin to Rivoroxaban - INR needs to be below 2.5

Hi all - I'm making the switch imminently but my anticoagulation team and the haematologist at the warfarin clinic have said as my INR was 3.5 on Thursday, I need to stop taking warfarin on Sunday and Monday and return for my INR test on Tuesday (because of the bank holiday weekend) and ensure it is below 2.5 before starting on Rivoroxaban. I am unsure of this advice and I did point out my concerns to the team - I don't think it is a good idea to stop taking warfarin for 2 days and think by reducing my dose (I was on 9/10/10mg) to 8mg for those two days, my INR would fall into the right range. Does anyone else have a view on this? My concern is that APS doesn't discriminate and I still need to be effectively anticoagulated (INR target range is 2-3). Thanks in advance.

11 Replies

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  • Hi

    I would share your concerns if I had been told to do this, it is essential to be properly anticoagulated at all times.

    When I switched from Warfarin to Frgamin shots I started the Frgamin and stopped taking Warfarin on the same day and my INR was around 4.0 on that day.

    Who is managing your APS treatment, not just the Warfarin clinic, but your overall treatment? Is there any way of talking to Prof Khamashta about this?

    Dave

  • HI, I echo advice here given by Dave, you need some more input regarding this, know it is a short phase but you still need to be safe. MaryF

  • Who is recommending you start on the Rivoroxaban? Unless it is St Thomas/Guys I would be very careful as this drug is still under trial with results still awaited. You therefore need to be under someone who is very specialised with APS before you take this step and they should know about your APS rather than just be treating you as another ordinary anticoagulation patient. There seems to be a push is some of the clinics to switch now because of the cost savings, however this is only for people who are AF patients. Speak to your APS specialist and make sure they are on board.

  • I switched from Warfarin to fragmin in January due to DVT whilst on Warfarin and had to stop for 24hrs before starting fragmin. I have now switched from fragmin to Rivoroxoban and was told to miss one injection before starting new meds. Day 3 of rivaroxaban and so glad injectons are finished but just getting used to new drug. INR is only measured while on Warfarin

  • Thanks for the replies and thanks Mary and Dave, I think I will just carry on but reduce my dose by 1mg each day which im sure will put me in the right region. I am under the care of my local hospital but also will see Prof K at London Bridge twice a year. APSnotFab, I keep seeing on this site that Rivaroxaban isnt yet approved for APS but this goes against all the advice I have heard from medical professionals and I find it very confusing! Prof K has said it is approved and my haematologist at the local hospital has also said it is approved for APS now by NICE but that warfatin is generally prescribed still. When you say it is not approved, what do you mean? The HSF website also hasnt updated its advice regarding rivaroxaban and I appreciate it is a new drug but I am finding it difficult to get an affirmation whether it is or is not approved for APS. As Prof K has recommended it for me, I am happy to go with his recommendation in either case but there does seem to be some confusion over this in the wider APS community. Thankyou once again for your replies, it is certainly helpful to have such a wonderful and reliable group of understanding people to bounce thoughts and questions off. We are very fortunate to have access to such a fantastic forum, thanks to you all and the hughes syndrome foundation.

  • Hi I was told by Prof Hunt that Rivaroxaban is only used for patients with an INR of up to 2.5 so not stable for INRs' above this but they are still researching it.

  • I don't know how the system works in UK-but here I have specialist approval for Rivaroxaban so I pay a lot less for monthly tabs. ($6 vs $94/month without approval) Generally when a drug is new it's approved for certain conditions-doesn't mean you can't take it for other things. It is often used shorter term for hip and knee replacements. Unstable INR on Warfarin and DVT after a year on Clexane (Enoxaparin) there wasn't a lot left in the tool box for me :)

    I also take an Aspirin 100mg daily on Haematologist say so. There is no test, so if you need dental extractions you need to stop it 24 hours before and commence 6 hours after-other surgery needs 48 hours off. It is an "easier" drug to stop and start than the other two. Although Vit K will not stop bleeding there is another blood factor (I think its called Cofact) that can be used in an emergency if you are VERY unlucky to need this.

  • Hi I agree with the other comments but would just add that if you miss 1 dose your INR will drop on average by 1.0 so missing 2 doses it would drop to approx. 1.5 which I think is too low so would be careful if I were you.

  • Hi. Snap. I've just started rxban too. I was told by haematologist that I cannot start whilst above 2.5. I took bloods on Thursday, and contacted the hospital on Friday to check my results. INR 1.7. So I was able to start RX on Friday evening. (Good Friday). To celebrate I've had a nice plate of Brussels, cabbage etc. Bloods on Tuesday. My inr was way out of control more than ever. The highest was 5.2 last Monday so I had to stop warfarin. Tested on Wednesday, still high so advised to stay of warfarin. I hope this reassures you that the 2.5 is the guideline recognised by the medics. I was told if it was 2.7, I would have to wait til it was below 2.5. It seems they are very strict on this. Good luck. Also, I read in the MHRA on 19/3/15,

    reports that some machines were giving false readings. I don't know if all the bloods are tested centrally or some of them end up in the clinic for testing.

  • Hi. I recently spoke to my haemo consultant re rivoroxaban, and to changing to it as inr so unstable, and I am long way from clinic. She said that it was unsuitable for those with ranges above 3. This usually means a thrombotic event has occurred, and my risk is high, so warfarin is still only effective drug for this circumstance. In their opinion, if you have or are high risk to thrombotic events, ie, have had history of, rivoroxaban has not been approved under these circumstances, and tests continue. That's what I was told.

  • Thanks again for your time and replies! I am happy to report that I didn't stop the Warfarin and just reduced my daily dose. I had my blood checked this morning and it was 2.4, so I started the Xarelto / Rivaroxaban this evening - so far so good!

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