# A 71-year-old patient with atrial fibrillation has been on warfarin for 5 years and is being transitioned to apixaban. Current INR is 2.6 (therapeutic). Which actions should the nurse plan during the warfarin-to-apixaban transition? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=372759&lang=en > language: en > subject: Adverse Effects/Contraindications/Interactions > category: PPT ## Question A 71-year-old patient with atrial fibrillation has been on warfarin for 5 years and is being transitioned to apixaban. Current INR is 2.6 (therapeutic). Which actions should the nurse plan during the warfarin-to-apixaban transition? Select all that apply. 1 Provide written discharge instructions covering bleeding precautions, missed-dose guidance for apixaban, and the difference from prior warfarin teaching. 2 Stop warfarin and start apixaban when the INR falls below 2.0, per manufacturer guidance. 3 Advise the patient to maintain consistent dietary vitamin K intake during the transition and while on apixaban to ensure stable anticoagulation levels. 4 Reinforce that INR monitoring is no longer needed once apixaban is started, but the nurse will check renal function (creatinine clearance) at baseline and periodically. 5 Educate the patient that there will be no overlap doses of warfarin and apixaban together — concurrent therapy raises bleeding risk. ## Explanation Option 1 is correct because discharge teaching must cover bleeding precautions, missed doses, and the differences between apixaban and warfarin. Option 2 is correct because warfarin is stopped and apixaban is started when the INR falls below 2.0, following manufacturer guidance. Option 3 is incorrect because apixaban does not interact with vitamin K, so the dietary consistency required with warfarin is no longer needed. Option 4 is correct because routine INR monitoring is not used for apixaban, while renal function should be assessed at baseline and periodically. Option 5 is correct because warfarin and apixaban are not overlapped; concurrent therapy would increase bleeding risk. ## In-depth explanation The warfarin-to-apixaban transition is a focused patient-safety topic. Per the apixaban prescribing information, warfarin is stopped and apixaban started when the INR is below 2.0; there is no overlap or bridging because dual anticoagulation increases bleeding risk. Once apixaban is started, INR monitoring is no longer needed for anticoagulation management; instead, the team checks creatinine clearance at baseline and periodically because dose reduction is required at CrCl below 50 with other criteria. The patient education shifts substantially: vitamin K intake no longer matters because apixaban does not interact with dietary vitamin K, so the food restrictions taught for warfarin can be relaxed. New teaching emphasizes bleeding precautions, missed-dose rules (take if within 6 hours of scheduled time, otherwise skip), avoidance of NSAIDs and aspirin unless prescribed, and holding apixaban before invasive procedures per provider order. ## Clinical scenario A **71-year-old patient with atrial fibrillation** on **warfarin for 5 years** is being transitioned to **apixaban**. **Current INR 2.6**. The nurse plans the transition. ## Key concepts - **Transition Rule** — Per apixaban prescribing information: stop warfarin and start apixaban when the INR is below 2.0. No overlap or bridging — concurrent warfarin plus apixaban produces dual anticoagulation and unacceptable bleeding risk. Other DOACs (rivaroxaban, dabigatran, edoxaban) have similar transition thresholds. - **Monitoring Shift** — Warfarin: INR every 1–4 weeks. Apixaban: no INR. Instead, baseline and periodic creatinine clearance, baseline LFTs, and clinical surveillance for bleeding. Dose reduction at CrCl <50 plus age >80 or weight <60 kg or serum creatinine >1.5. - **Education Reset** — Patients transitioning from warfarin must be re-educated. Stop: "consistent vitamin K," "monthly INR." Start: "no dietary vitamin K restriction," "missed-dose rule (within 6 hr take, otherwise skip), bleeding precautions, hold for procedures." 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