Warfarin administration and monitoring

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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)." Current recommendations on chronic warfarin management are mainly based on the RE-LY trial which was published in 2009 with modifications due to subsequent practice guidelines by the American College of Chest Physicians in 2012.

Adjustment of Warfarin Dose According to INR

INR Value	Response per RE-LY	Alternative by ACCP
≤ 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:

• 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