Warfarin administration and monitoring: Difference between revisions
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==Overview== | ==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 [[IN]]R 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)."<ref name="pmid22315259">{{cite journal| author=Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ et al.| title=Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e152S-84S | pmid=22315259 | doi=10.1378/chest.11-2295 | pmc=PMC3278055 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315259 }} </ref> Current recommendations on chronic warfarin management are mainly based on the RE-LY trial<ref name="pmid19717844">{{cite journal| author=Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A et al.| title=Dabigatran versus warfarin in patients with atrial fibrillation. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 12 | pages= 1139-51 | pmid=19717844 | doi=10.1056/NEJMoa0905561 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19717844 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20083817 Review in: Ann Intern Med. 2010 Jan 19;152(2):JC1-2] </ref> which was published in 2009 with modifications due to subsequent practice guidelines by the [[American College of Chest Physicians]] in 2012.<ref name="pmid22315259"/> | 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 [[IN]]R 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)."<ref name="pmid22315259">{{cite journal| author=Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ et al.| title=Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e152S-84S | pmid=22315259 | doi=10.1378/chest.11-2295 | pmc=PMC3278055 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315259 }} </ref> Current recommendations on chronic warfarin management are mainly based on the RE-LY trial<ref name="pmid19717844">{{cite journal| author=Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A et al.| title=Dabigatran versus warfarin in patients with atrial fibrillation. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 12 | pages= 1139-51 | pmid=19717844 | doi=10.1056/NEJMoa0905561 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19717844 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20083817 Review in: Ann Intern Med. 2010 Jan 19;152(2):JC1-2] </ref> which was published in 2009 with modifications due to subsequent practice guidelines by the [[American College of Chest Physicians]] in 2012.<ref name="pmid22315259" /> | ||
==Adjustment of Warfarin Dose According to INR== | ==Adjustment of Warfarin Dose According to INR== | ||
| Line 10: | Line 10: | ||
{| class="wikitable" | {| class="wikitable" | ||
! INR Value | ! INR Value | ||
! Response per RE-LY<ref name="pmid19717844"/> | ! Response per RE-LY<ref name="pmid19717844" /> | ||
! Alternative by ACCP<ref name="pmid22315259"/> | ! Alternative by ACCP<ref name="pmid22315259" /> | ||
|- | |- | ||
| ≤ 1.5 | | ≤ 1.5 | ||
| ↑ weekly dose by 15% | | ↑ weekly dose by 15%<br />Repeat INR in 7-10 days. | ||
| Patients with stable INRs at baseline, now with a single subtherapeutic INR value: no routine bridging with heparin | | Patients with stable INRs at baseline, now with a single subtherapeutic INR value: no routine bridging with heparin | ||
|- | |- | ||
| 1.51-1.99 | | 1.51-1.99 | ||
| ≤1.5: ↑ weekly dose by 10% | | ≤1.5: ↑ weekly dose by 10%<br />Repeat INR in 7-10 days. | ||
| Patients with stable INRs at baseline, 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 at baseline, now with a single out-of-range INR of < 0.5 below or above therapeutic: no change and retest 1-2 weeks | ||
|- | |- | ||
| 2-3 | | 2-3 | ||
| colspan="2" style="text-align: center;background-color:lightgreen" | No dose adjustment | | colspan="2" style="text-align: center;background-color:lightgreen" | No dose adjustment* | ||
|- | |- | ||
| 3.01 - 4 | | 3.01 - 4 | ||
| | | "Do not hold warfarin. If high on 2 consecutive occasions, decrease weekly dose by 10%" | ||
| Patients with stable INRs at baseline, 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 at baseline, 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 | | 4.01 - 4.99 | ||
| Hold dose for 1 day, then ↓ weekly dose by 10% | | Hold dose for 1 day, then ↓ weekly dose by 10%<br />Repeat INR in 7-10 days. | ||
| rowspan="2" | Patients with INRs 4.5 - 10 and with no evidence of bleeding: ACCP suggests against the routine use of vitamin K | | rowspan="2" | Patients with INRs 4.5 - 10 and with no evidence of bleeding: ACCP suggests against the routine use of vitamin K | ||
|- | |- | ||
| 5 - 8.99 | | 5 - 8.99 | ||
| Hold dose until INR therapeutic, then ↓ weekly dose by 15% | | Hold dose until INR therapeutic, then ↓ weekly dose by 15%<br />Repeat INR in 1 day. | ||
|- | |- | ||
| ≥ 9.0 | | ≥ 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 | ||
|- | |||
| colspan="3" |* Per ACCP, "For patients taking VKA therapy with consistently stable INRs, we suggest an INR testing frequency of up to 12 weeks rather than every 4 weeks". One definition of consistent stability is 6 months.<ref name="pmid22084331">{{cite journal| author=Schulman S, Parpia S, Stewart C, Rudd-Scott L, Julian JA, Levine M| title=Warfarin dose assessment every 4 weeks versus every 12 weeks in patients with stable international normalized ratios: a randomized trial. | journal=Ann Intern Med | year= 2011 | volume= 155 | issue= 10 | pages= 653-9, W201-3 | pmid=22084331 | doi=10.7326/0003-4819-155-10-201111150-00003 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22084331 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22431689 Review in: Ann Intern Med. 2012 Mar 20;156(6):JC3-3] </ref> | |||
|} | |} | ||
Based on the existing medical research and [[clinical practice guideline]]s, 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 [http://wichita.kumc.edu/im KUSM-W] and is located at [http://sumsearch.org/warfarinbywichita/ Warfarin by Wichita]. | Based on the existing medical research and [[clinical practice guideline]]s, 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 [http://wichita.kumc.edu/im KUSM-W] and is located at [http://sumsearch.org/warfarinbywichita/ Warfarin by Wichita]. | ||
== Point of care testing == | |||
According to a [[systematic review]], of [[randomized controlled trial]]s, that compared varioius methods of management to traditional [[venipuncture]] with decisions by a [[health care provider]]<ref name="pmid23074516">{{cite journal| author=Health Quality Ontario| title=Point-of-Care International Normalized Ratio (INR) Monitoring Devices for Patients on Long-term Oral Anticoagulation Therapy: An Evidence-Based Analysis. | journal=Ont Health Technol Assess Ser | year= 2009 | volume= 9 | issue= 12 | pages= 1-114 | pmid=23074516 | doi= | pmc=PMC3377545 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23074516 }} </ref>: | |||
* Traditional venipuncture: time in therapeutic range (TTR): 64% | |||
** Patients self-testing and self-management: 4.2% increase in TTR | |||
** Patients self-testing but management by a health care provider: 7.2% increase in TTR | |||
** Point of care testing and management in health care practitioners' offices: 6.1% increase in TTR | |||
==Pill selection== | |||
Recommendations exist for consistent use of one pill size by anticoagulation clinics.<ref name="pmid15926414">{{cite journal| author=Ebell MH| title=Evidence-based adjustment of warfarin (Coumadin) doses. | journal=Am Fam Physician | year= 2005 | volume= 71 | issue= 10 | pages= 1979-82 | pmid=15926414 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15926414 }} </ref> The importance of choice of pill size is not clear.<ref name="pmid10600087">{{cite journal| author=Wong W, Wilson Norton J, Wittkowsky AK| title=Influence of warfarin regimen type on clinical and monitoring outcomes in stable patients in an anticoagulation management services. | journal=Pharmacotherapy | year= 1999 | volume= 19 | issue= 12 | pages= 1385-91 | pmid=10600087 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10600087 }} </ref><ref name="pmid12173723">{{cite journal| author=Manning DM| title=Toward safer warfarin therapy: does precise daily dosing improve international normalized ratio control? | journal=Mayo Clin Proc | year= 2002 | volume= 77 | issue= 8 | pages= 873-5 | pmid=12173723 | doi=10.4065/77.8.873-a | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12173723 }} </ref> | |||
==Management of Warfarin Related Bleeding== | ==Management of Warfarin Related Bleeding== | ||
Revision as of 21:04, 20 April 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]
Adjustment of Warfarin Dose According to INR
| INR Value | Response per RE-LY[2] | Alternative by ACCP[1] |
|---|---|---|
| ≤ 1.5 | ↑ weekly dose by 15% Repeat INR in 7-10 days. |
Patients with stable INRs at baseline, now with a single subtherapeutic INR value: no routine bridging with heparin |
| 1.51-1.99 | ≤1.5: ↑ weekly dose by 10% Repeat INR in 7-10 days. |
Patients with stable INRs at baseline, 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 | "Do not hold warfarin. If high on 2 consecutive occasions, decrease weekly dose by 10%" | Patients with stable INRs at baseline, 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% Repeat INR in 7-10 days. |
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% Repeat INR in 1 day. | |
| ≥ 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 |
| * Per ACCP, "For patients taking VKA therapy with consistently stable INRs, we suggest an INR testing frequency of up to 12 weeks rather than every 4 weeks". One definition of consistent stability is 6 months.[3] | ||
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.
Point of care testing
According to a systematic review, of randomized controlled trials, that compared varioius methods of management to traditional venipuncture with decisions by a health care provider[4]:
- Traditional venipuncture: time in therapeutic range (TTR): 64%
- Patients self-testing and self-management: 4.2% increase in TTR
- Patients self-testing but management by a health care provider: 7.2% increase in TTR
- Point of care testing and management in health care practitioners' offices: 6.1% increase in TTR
Pill selection
Recommendations exist for consistent use of one pill size by anticoagulation clinics.[5] The importance of choice of pill size is not clear.[6][7]
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
- ↑ Schulman S, Parpia S, Stewart C, Rudd-Scott L, Julian JA, Levine M (2011). "Warfarin dose assessment every 4 weeks versus every 12 weeks in patients with stable international normalized ratios: a randomized trial". Ann Intern Med. 155 (10): 653–9, W201–3. doi:10.7326/0003-4819-155-10-201111150-00003. PMID 22084331. Review in: Ann Intern Med. 2012 Mar 20;156(6):JC3-3
- ↑ Health Quality Ontario (2009). "Point-of-Care International Normalized Ratio (INR) Monitoring Devices for Patients on Long-term Oral Anticoagulation Therapy: An Evidence-Based Analysis". Ont Health Technol Assess Ser. 9 (12): 1–114. PMC 3377545. PMID 23074516.
- ↑ Ebell MH (2005). "Evidence-based adjustment of warfarin (Coumadin) doses". Am Fam Physician. 71 (10): 1979–82. PMID 15926414.
- ↑ Wong W, Wilson Norton J, Wittkowsky AK (1999). "Influence of warfarin regimen type on clinical and monitoring outcomes in stable patients in an anticoagulation management services". Pharmacotherapy. 19 (12): 1385–91. PMID 10600087.
- ↑ Manning DM (2002). "Toward safer warfarin therapy: does precise daily dosing improve international normalized ratio control?". Mayo Clin Proc. 77 (8): 873–5. doi:10.4065/77.8.873-a. PMID 12173723.