Warfarin administration and monitoring: Difference between revisions
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! Alternative by ACCP<ref name="pmid22315259"/> | ! Alternative by ACCP<ref name="pmid22315259"/> | ||
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| | | ≤ 1.5 | ||
| | | ↑ weekly dose by 15% | ||
| Patients with stable INRs now with a single subtherapeutic INR value, no routine bridging with heparin. | | Patients with stable INRs now with a single subtherapeutic INR value, no routine bridging with heparin. | ||
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| 1.51-1.99 | | 1.51-1.99 | ||
| | | ≤1.5: ↑ weekly dose by 10% | ||
| Patients with stable INRs now with a single out-of-range INR of < 0.5 below or above therapeutic, no change and retest 1-2 weeks. | | Patients with stable INRs now with a single out-of-range INR of < 0.5 below or above therapeutic, no change and retest 1-2 weeks. | ||
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| 3.01 - 4 | | 3.01 - 4 | ||
| | | ↓ weekly dose by 10% | ||
| Patients with stable INRs now with a single out-of-range INR of < 0.5 below or above therapeutic: no change and retest 1-2 weeks. | | Patients with stable INRs now with a single out-of-range INR of < 0.5 below or above therapeutic: no change and retest 1-2 weeks. | ||
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| Hold dose until INR therapeutic, then ? weekly dose by 15% | | Hold dose until INR therapeutic, then ? weekly dose by 15% | ||
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| | | ≥ 9.0 | ||
| Hold warfarin and give vitamin K 5.0-10mg PO. Monitor more frequently and repeat Vitamin K if necessary | | Hold warfarin and give vitamin K 5.0-10mg PO. Monitor more frequently and repeat Vitamin K if necessary | ||
| Patients with INRs > 10.0 with no evidence of bleeding, ACCP suggests that oral vitamin K be administered. | | Patients with INRs > 10.0 with no evidence of bleeding, ACCP suggests that oral vitamin K be administered. | ||
Revision as of 01:41, 19 February 2015
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The optimal dose of warfarin among patients on chronic anticoagulation represents a balance between the highest thrombosis prevention and the lowest risk of bleeding. In order to optimize the efficacy to safety ratio, dosing of warfarin requires INR monitoring with a target INR range of 2-3. The 2012 American College of Chest Physicians (ACCP) clinical practice guidelines, "suggest using validated decision support tools (paper nomograms or computerized dosing programs) rather than no decision support (Grade 2C)."[1]
Current recommendations on chronic warfarin management are mainly based on the RE-LY trial[2] which was published in 2009 with modifications due to subsequent practice guidelines by the American College of Chest Physicians in 2012[1].
| INR Value | Response per RE-LY[2] | Alternative by ACCP[1] |
|---|---|---|
| ≤ 1.5 | ↑ weekly dose by 15% | Patients with stable INRs now with a single subtherapeutic INR value, no routine bridging with heparin. |
| 1.51-1.99 | ≤1.5: ↑ weekly dose by 10% | Patients with stable INRs now with a single out-of-range INR of < 0.5 below or above therapeutic, no change and retest 1-2 weeks. |
| 2-3 | No dose adjustment | |
| 3.01 - 4 | ↓ weekly dose by 10% | Patients with stable INRs now with a single out-of-range INR of < 0.5 below or above therapeutic: no change and retest 1-2 weeks. |
| 4.01 - 4.99 | Hold dose for 1 day, then ? weekly dose by 10% | Patients with INRs 4.5 - 10 and with no evidence of bleeding, ACCP suggests against the routine use of Vitamin K. |
| 5 - 8.99 | Hold dose until INR therapeutic, then ? weekly dose by 15% | |
| ≥ 9.0 | Hold warfarin and give vitamin K 5.0-10mg PO. Monitor more frequently and repeat Vitamin K if necessary | Patients with INRs > 10.0 with no evidence of bleeding, ACCP suggests that oral vitamin K be administered. |
Based on the existing medical research and clinical practice guidelines, institutions have algorithms to standardize the chronic administration of warfarin. For instance, the RE-LY and ACCP guidelines have been combined by the Department of Internal Medicine at KUSM-W and is located at Warfarin by Wichita.
Management of Warfarin Related Bleeding
The management of bleeding among patients on warfarin includes:[1]
- Rapid reversal of anticoagulation with the administration of four-factor prothrombin complex concentrate (PCC), PLUS
- Slow IV injection of 5 to 10 mg vitamin K
References
- ↑ 1.0 1.1 1.2 1.3 Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ; et al. (2012). "Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e152S–84S. doi:10.1378/chest.11-2295. PMC 3278055. PMID 22315259.
- ↑ 2.0 2.1 Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A; et al. (2009). "Dabigatran versus warfarin in patients with atrial fibrillation". N Engl J Med. 361 (12): 1139–51. doi:10.1056/NEJMoa0905561. PMID 19717844. Review in: Ann Intern Med. 2010 Jan 19;152(2):JC1-2