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CC BY 4.0 · Semin Thromb Hemost
DOI: 10.1055/a-2734-2293
Commentary

Transitioning of Patients from Direct-Acting Oral Anticoagulant to Heparin: Impact on Laboratory Testing

Autoren

  • Deepa J. Arachchillage

    1   Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, United Kingdom
    2   Department of Haematology, Imperial College Healthcare NHS Trust, London, United Kingdom

  • Saravanan Vinayagam

    3   North West London Pathology, Imperial College Healthcare NHS Trust, London, United Kingdom

  • Annie Parsons

    3   North West London Pathology, Imperial College Healthcare NHS Trust, London, United Kingdom

  • Nilanthi Karawitage

    3   North West London Pathology, Imperial College Healthcare NHS Trust, London, United Kingdom

  • Mike Laffan

    1   Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, United Kingdom

Funding Information D.J.A. was funded by the Medical Research Council, United Kingdom (MR/Z505274/1), and infrastructure support for some of the work was provided by the NIHR Imperial Biomedical Research Centre (BRC).
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Abstract

Direct oral anticoagulants (DOACs), including direct thrombin inhibitors (dabigatran) and direct factor Xa inhibitors (apixaban, rivaroxaban, edoxaban), have transformed anticoagulant management in recent years due to their predictable pharmacodynamics, rapid onset of action, and fixed dosing without the need for routine laboratory monitoring. Unfractionated heparin (UFH) remains the anticoagulant of choice for patients who are acutely unwell and treated in intensive care units due to its short half-life, reversibility, ease of dose titration, and nonrenal dependent excretion. It is therefore not uncommon for an individual's anticoagulation management to require rapid changing from DOAC to UFH. Due to UFH's complex pharmacokinetics, including nonspecific binding to acute phase proteins and dose-dependent clearance, careful laboratory monitoring, generally with activated partial thromboplastin time (APTT) or anti-factor Xa (anti-Xa) activity, is necessary. When transitioning from a DOAC to UFH, overlapping pharmacologic effects can significantly interfere with coagulation assays, particularly if residual DOAC levels persist at the time UFH is initiated. DOACs can prolong the APTT and elevate anti-Xa activity, leading to overestimation of UFH activity, inappropriate dose adjustments, and increased risk of bleeding or thromboembolic events. Here, we examine the laboratory implications of transitioning from DOAC therapy to UFH, with a focus on the performance and interpretation of APTT and anti-Xa assays in the presence of residual DOAC levels and how to overcome the interference of DOAC in UFH monitoring. We suggest an algorithm to follow during this transition.

Keywords

direct oral anticoagulants - heparin - anti-Xa - activated partial thromboplastin time - monitoring

Contributors' Statement

D.J.A. conceived the study, designed the study, interpreted the data, wrote the first draft, and edited the manuscript. S.V., A.P., and N.K. performed the laboratory assays and reviewed the manuscript. M.L. reviewed and edited the manuscript. All authors reviewed and approved the final version of the manuscript.




Publikationsverlauf

Eingereicht: 11. Juli 2025

Angenommen: 12. September 2025

Artikel online veröffentlicht:
13. November 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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