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)."[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% 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]

References

  1. 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. 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