Warfarin management adult ambulatory clinical practice guideline. Discontinue heparin if platelets decrease by 50% from baseline and proceed with hit. Clinical practice guideline for anticoagulation management this guideline is to inform practitioners of the standard of care for providing safe and effective anticoagulation management for ambulatory patients. Warfarin maintenance dosing nomogram anticoagulation. Warfarin initiation dosing protocol week 1 with inr goal 23 frequency of inr monitoring after initiation of warfarin. Adult heparin drip protocol ventura county, california. Heparin will not be held in the event there are no baseline labs. Clinical practice guideline for anticoagulation management.
Warfarin dose reminder chart american family physician aafp. Patients who have the aa genotype or aa haplotype are the most warfarin. Patients who have been on these drugs prior to starting warfarin can be included. Warfarin is the most commonly prescribed anticoagulant in the uk and the one most frequently associated with both fatal medication errors and litigation claims 1.
Nomograms for maintenance of warfarin therapy are also recommended in the accp guidelines, 6 and they have been shown to increase the ttr. This often requires holding or reducing warfarin dose by 50% for 12 days after admission, but as they diurese and improve, they often require their previous warfarin does. At the mayo clinic hospitals in rochester, minnesota, we set out to improve the safety of warfarin management among surgical and nonsurgical inpatients. Foster, pharmacist approved by wirral drug and therapeutics committee. Rarely, clots can break into pieces and travel in the blood stream. Anticoagulation management is a complex process, and is susceptible to multiple patient, environmental, disease state. Practical tips for warfarin dosing and monitoring cleveland clinic. Beneficial blood clots prevent or stop bleeding, but harmful blood clots can cause a heart attack, stroke, deep vein thrombosis or pulmonary embolism. Warfarin dosing guideline summary warfarin coumadin is a vitamin k antagonist used to treat a number of hypercoagulable disease states. When initiating warfarin for the treatment of vte the patient should be prescribed treatment dose of lmwh tinzaparin alongside warfarin for at least 5 days or until the inr is within the therapeutic range whichever is the longer. Blood clots can block a blood vessel and cut off the blood supply to a body part. Guidelines for warfarin management in the community.
Expanded valve types in warfarin inr and length of treatment table p. Warfarin, a vitamin k antagonist, is an oral anticoagulant indicated for the prevention and treatment of venous thrombosis and its. Bleeding, particularly in the setting of overanticoagulation, is a major concern. Please see the attached document for dosing guidelines for lmwhs at uw medicine. Initial warfarin dosing should be tailored based on patient bleed risk, potential sensitivity to warfarin, indication, goal inr range, and if potential drug interactions are present. Dosing guidelines for rapid reversal in preparation for invasive procedure. Furthermore, inrs greater than 5 commonly occur in hit patients during argatroban monotherapy and argatrobanwarfarin cotherapy, without major bleeding. Your doctor has highlighted a row below showing the total amount of warfarin coumadin you should take each week. Bivalirudin orders and dosing protocol for heparininduced thrombocytopenia hit 304009 9 physician orders patient information warfarin coumadin per md routine, see admin instructions initiate warfarin coumadin only when platelet count has recovered usually greater than 150,000. During the initial stage of therapy, expect to check the inr frequently. The protocol for anticoagulation below is recommended. Safe and effective anticoagulation in the outpatient setting evidencebased synthesis program this report is based on research conducted by the evidencebased synthesis program esp center located at the minneapolis va medical center, minneapolis, mn funded by the department of veterans affairs, veterans health administration, office of research. Safe and effective anticoagulation in the outpatient setting. Methods a multidisciplinary team designed a pharmacistmanaged warfarin protocol pmwp which designated warfarin dosing to inpatient.
Bivalirudin orders and dosing protocol for heparininduced thrombocytopenia hit 304009 9 physician orders patient information warfarin coumadin per md routine, see admin instructions initiate warfarin coumadin only when platelet count. Coumadin clinic protocol 2007 san francisco health plan. General dosing guidelines anticoagulation services. A good warfarin management plan, including ongoing patient education, followup, dosing tools, and involved caregiversother health professionals, can maximize the benefit to harm ratio. Argatroban is not for use in patients with moderate to severe hepatic insufficiency. Randomized trials22,23have shown that patients are more likely to have a therapeutic inr 3 to 5 days after starting warfarin with a 5mg dose than with a 10mg dose. This protocol serves to optimize these therapies, improve patient outcomes, and ensure patient safety. Adjustments can be made slightly below or above range e. Inr dose day 17 3 mg daily and check in 1 week day 8 this protocol is only valid if the patient has taken 7 days warfarin. This algorithm has been developed for md anderson using a multidisciplinary approach considering circumstances particular to md andersons specific patient population, services and structure, and clinical information. Protocol this trial protocol has been provided by the authors to give readers additional information about their work.
Heparin induced thrombocytopenia hit treatment page 1 of 7. Poor compliance with drug therapy error or missed dose. Warfarin inhibits the product of this gene vkor, a key enzyme in the vitamin k cycle. If inr remains high, give an additional dose of vitamin k 1 mg 2 mg orally. Phytonadione vitamin k dosing guidelines authorized prescriber order is required for holding of warfarin dosing or administration of phytonadione. Warfarin dosage adjustment algorithm thames valley family health. But if you want to get really familiar with warfarin and how to dose it, check out our magnum opus on the subject warfarin. The kcentra dosing and administration information is in appendix b d. Only accredited practitioners who meet the service specification and sign up to the service level agreement should provide this service. This protocol is only valid if the patient has taken 7 days warfarin before the day 8 inr. Transitioning from argatroban to warfarin therapy in patients. Identifying and implementing solutions to achieve safer prescribing and monitoring is imperative to improve patient safety.
Schedule patients for office visits to address issues of compliance, bleeding, adverse reactions, communication problems or other problems that are difficult to manage over the telephone. Consider warfarin versus direct thrombin inhibitor dabigatran or factor xa inhibitors. If a patient has taken warfarin in the past their previous dose requirements should be considered. Bivalirudin see appendix a for dosing heparin induced thrombocytopenia hit treatment page 1 of 7 disclaimer. Adjust coumadinwarfarin dose per anticoagulation clinic protocol or a physicians order, if deemed more conservative. Warfarin brand names coumadin and jantoven is a prescription medication used to prevent harmful blood clots from forming or growing larger. Warfarin should be started at a dose of 5 mg per day. Warfarin dosing should include appropriate assessment of other factors that influence inr clinical condition, dose of initiated antimicrobial, inr trends, other drug interactions, nutrition, compliance, etc.
However to minimize cancelled cardioversions due to low inrs a target inr of 3. Selection of initial warfarin dose along indication and target range for treatment. Warfarin initiation nomogram 5mg starting dose, target inr range 231. Review august 2015 page 4 of 16 recommended treatment duration in venous thromboembolism. Its lifethreatening interactions and side effects are a concern for all doctors. Includes dosages for myocardial infarction, prevention of thromboembolism in atrial fibrillation, myocardial infarction prophylaxis and more. In order to optimize the therapeutic effect and minimize complications such as bleeding, close monitoring of the degree of anticoagulation is required. Division of pharmacotherapy, the university of texas at austin college of pharmacy. This article covers the bare essentials of dosing warfarin. Also, a 10mg dose more frequently results in supratherapeutic inr values. Phytonadione vitamin k dosing guidelines appendix b. Imagine its your first week of an appe rotation at an anticoagulation clinic. Administration of kcentra should not be delayed for inr results e.
It is not a substitute for appropriate clinical evaluation and does not supersede clinical judgment. Warfarin therapy management province of british columbia. Inr dose day 17 3 mg daily and check in 1 week day 8 this protocol. Pharmacists will have the ability to order a baseline ptinr prior to initiation of warfarin therapy regardless of enrollment in the collaborative practice protocol. Warfarin management adult inpatient clinical practice guideline. Table 5, 6 and 7 provide recommendations for warfarin dosing for inr goals of 1.
For those with active clot or high risk for clotting, there must be a. Obtain ptt 6 hours after initiation of heparin and after any subsequent changes until therapeutic x 2, then every am. Guideline on oral anticoagulation with warfarin this guideline is intended to be used in derbyshire to support the primary care led inr monitoring service commissioned in derbyshire. Warfarin management adult ambulatory clinical practice.
The goal of anticoagulant therapy with warfarin is to administer the lowest effective dose of the drug to maintain the target international normalized ratio inr. After warfarin is initiated, check the inrideally daily, but at least every 3 daysuntil 2 consecutive results are within the therapeutic range. Detailed warfarin dosage information for adults and children. To initiate the protocol for inpatient, the patients appropriatelycredentialed practitioner will select the warfarin dosed per collaborative practice protocol order in the cpoe system. These algorithms are meant to serve as a clinical guide, and deviation from them will occur based on clinical. Predicted maintenance dosage of warfarin based on inr after 2 weeks of 2mgday 1. It may not be applicable to outpatient use in which daily inrs are not practical.
Pharmacotherapy education and research center, university of texas health science center at san. Guidelines for warfarin management in the community queensland. Warfarin maintenance dosing nomogram anticoagulation services. Inpatient guideline for management of significant warfarin.
But use daily dosing versus monfri and satsun dosing whenever possible. The responsibility of the clinical provider md, pa, npp i. Procedures for warfarin collaborative practice agreement 4. Use one of the following regimens when starting warfarin. Collaborative drug therapy management protocol anticoagulation. Randomized trials22,23 have shown that patients are more likely to have a thera peutic inr 3 to 5 days after. Please see full prescribing information for additional dosing considerations. Because warfarin interferes with the formation of blood clots, it is called an anticoagulant pdf. Starting warfarin warfarin is commonly used to decrease the risk of systemic arterial thromboembolism eg, warfarin can paradoxically exert a procoagulant response by interfering with proteins c and s warfarin dosing jaffer and bragg what to tell a patient taking warfarin indicate the reason for starting warfarin and how it relates to clot. Guidelines for warfarin management in the community 2 1. How to manage warfarin therapy australian prescriber.
A patients guide to taking warfarin american heart. Warfarin is recommended for the prevention of systemic embolism, stroke associated with atrial fibrillation, and venous thromboembolism. Furthermore, inrs greater than 5 commonly occur in hit patients during argatroban monotherapy and argatroban warfarin cotherapy, without major bleeding. Clinical material offered in this guideline does not replace or remove clinical judgement or the. Warfarin initiation dosing protocol week 1 with inr. Warfarin is a very individualized medication without a standard dose. Schedule patients for office visits to address issues of compliance, bleeding, adverse reactions, communication problems or other problems that are. Bivalirudin orders and dosing protocol for heparininduced. Warfarin is highly susceptible to medication interactions that may affect the absorption and metabolism of warfarin, and the efficacy of warfarins inhibition of clotting factor synthesis. Frequency of inr monitoring for maintenance of warfarin. The time in therapeutic range ttr is an accepted measure of the quality of warfarin dosing and inr control. This algorithm was developed for inpatients started on 5mg with an inr target range of 23 and monitored with daily inrs.
Give vitamin k 2 mg 4 mg orally inr should be reduced within 24 hours. Maintenance warfarin dose adjustments should be based on current inr results and trends and patient assessment of any missed doses, drug interactions, dietary intake or supplements, documentation of bleeding, or other changes that may affect the inr. Restart warfarin at lower dose once inr is within therapeutic range. Transitioning from argatroban to warfarin therapy in. Improving inpatient warfarin therapy safety using a. U n c m e d i c a l c e n t e r g u i d e l i n e emergent. See appendix 3, recommended inr target and duration of warfarin therapy by indication.
Second dose of warfarin give same dose as day before if 0. Table 5, 6 and 7 provide recommendations for warfarin dosing for inr goals of. Warfarin initiation, anticoagulation clinic uc san diego. The fennerty warfarin loading protocol published in 1984 was. Warfarin dosage adjustment algorithm anticoagulation management is a complex process, and is susceptible to multiple patient, environmental, disease state, and medication interactions. Switching to xarelto from warfarin stop warfarin and start xarelto when inr is apr 01, 2016 fixed dose 4fpcc for urgent warfarin reversal. Warfarin maintenance dosing protocol with inr goal 1. Introduction safe management of warfarin in the inpatient setting can be challenging.
After a minimum 5day overlap of fondaparinux and warfarin, discontinue fondaparinux when the inr is between 23 and continue with warfarin monotherapy3 transition from bivalirudin or argatroban to doac or fondaparinux stop bivalirudin or argatroban infusion and begin doac or fondaparinux within 2 hours see appendix b for dosing. Refer to trust protocol tinzaparin and unfractionated heparin in adults. The maintenance dose of warfarin to achieve a therapeutic inr varies considerably between individuals, and the dose must be individualised to each patient. Oral anticoagulant warfarin guidelines oxford university hospitals. Patients initiated on warfarin while admitted to an inpatient care unit 4. The american college of chest physicians accp, american heart association.
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