In the eligible studies, the LMWH- bridging strategy was implemented only when the patient was at high thromboembolic risk; thus, intervention and control groups had important differences. The intervention was associated with a lower major bleeding risk (ARR, 1 fewer event per 1000), but no reliable RR and 95% CI could be estimated because very few bleeding events were observed and none occurred in the LMWH-bridging group, leaving very low certainty evidence regarding the risk of adverse effects. Other EtD criteria and considerations. LMWH-bridging therapy is more expensive than overlapping DOAC therapy, potentially disadvantaging patients in lower socioeconomic strata. Patients may prefer DOAC overlap, as they would avoid the inconvenience and expense of LMWH injections. Careful INR monitoring during transitions to VKA is always required, regardless of bridging strategy. Conclusions and research needs for this recommendation. The net health benefit/harm associated with using LMWH-bridging therapy during transitions from DOAC to VKA compared with 27 NOVEMBER 2018 x VOLUME 2, NUMBER 22 ASH 2018 VTE GUIDELINES: ANTICOAGULATION MANAGEMENT 3271 overlapping DOAC with VKA alone remains very uncertain, but use of LMWH is certain to increase burden and cost. In an anonymous vote of 9 eligible panel members, 6 voted for a conditional recommendation against LMWH-bridging therapy, and 3 voted for a conditional recommendation for either LMWH-bridging therapy or overlapping DOAC. To minimize DOAC interference with the INR, the panel suggests measuring the INR just before the next DOAC dose if overlapping DOAC therapy is used. However, providers will need to be aware of the varying potential among DOACs to influence INR results. Ultimately, the strategy for transitioning from DOAC to VKA should be based on patient preference and willingness to use and ability to afford injections. 