DECISION
- The senior clinician decides to anticoagulate orally, including duration and intensity of treatment
Choice of rapid or slow anticoagulation
Choose:
- Rapid anticoagulation with concurrent LMWH or heparin e.g. for VTE, follow RAPID ANTICOAGULATION
- Slow anticoagulation without concurrent LMWH or heparin e.g. for AF, follow SLOW ANTICOAGULATION
RAPID ANTICOAGULATION
with concurrent heparin
Who initiates?
- Refer inpatients to an anticoagulation management service (AMS)
- Only if patient not referred to AMS, follow this guideline
Review clinical condition
Medication history
- Determine any significant interactions with warfarin
- remember herbal remedies
- Consider whether to discontinue or substitute medications
- particularly important for ‘as required’ medications e.g. NSAIDs, where the interaction may be inconsistent
- Seek further information from medicines information or AMS where necessary
Increased sensitivity to warfarin
- Frail, sick, have multiple comorbidities or take multiple medication
- Aged >80 yr
- Significantly underweight
- Congestive cardiac failure
- Abnormal liver function
- Receiving parenteral nutrition or drugs that potentiate warfarin significantly (see BNF Appendix 1)
Counsel patient
- Reason, risks and benefits of oral anticoagulation
- bleeding risk
- drug interactions (including alcohol)
- need for regular INR monitoring
- Provide anticoagulation information pack
Dose prediction
- Anticoagulation with warfarin takes effect only in 72–96 hrs after first dose
- The following algorithm allows the maintenance dose of warfarin to be predicted over 4 days by optimal interpretation of timed daily INR measurements
- Use INR to guide the selection of daily warfarin dose
- even during concurrent anticoagulant treatment with unfractionated heparin, dalteparin or any other low-molecular-weight heparin
- All warfarin tablets are scored, and
- any doses recommended can be administered by use of 1 mg, 3 mg and 5 mg tablets
Increased sensitivity to warfarin
- If patient has increased sensitivity to warfarin, use half the doses recommended below
Day 1
- Take blood for measurement of INR
- If INR ≥1.4, this predictive method cannot be used
- the choice of dose must rely on clinical judgement alone
- seek advice from AMS
- If INR <1.4 and no increased sensitive to warfarin, give warfarin 10 mg before evening meal between 1700 and 1800 hr
- remember to halve doses in sensitive patients
Day 2
- Take blood between 0900 hr and 1000 hr (16 hr after first dose of warfarin)
- Measure INR and use the result to select next dose
- remember to halve doses suggested in sensitive patients
Enter INR (for day 2 only):
Day 3
- Take blood between 0900 hr and 1000 hr (16 hr after second dose of warfarin)
- Measure INR and use the result to select next dose
- remember to halve doses suggested in sensitive patients
Enter INR (for day 3 only):
Day 4
- Take blood between 0900 hr and 1000 hr (16 hr after third dose of warfarin)
- Measure INR and use the result to select next dose
- remember to halve doses suggested in sensitive patients
Enter INR (for day 4 only):
Subsequent management
- The dose selected on day 4 is the predicted maintenance dose necessary to achieve a stable INR in the range 2–4
- Watch for INR instability due to changing/starting/stopping of interacting medication or diet (see BNF appendix 1)
- Make dose adjustments after end of initiation regimen onward intuitively
- If concerns of overanticoagulation, see Warfarin overanticoagulation
DISCHARGE
- Refer patients stabilised on warfarin to AMS for ongoing monitoring
- Order TTO for warfarin along with other medication
SLOW ANTICOAGULATION
Who initiates?
- Refer inpatients to an anticoagulation management service (AMS)
- Only if patient not referred to AMS, follow this guideline
Review clinical condition
Medication history
- Determine any significant interactions with warfarin
- remember herbal remedies
- Consider whether to discontinue or substitute medications
- particularly important for ‘as required’ medications e.g. NSAIDs, where the interaction may be inconsistent
- Seek further information from medicines information or AMS where necessary
Increased sensitivity to warfarin
- Frail, sick, have multiple comorbidities or take multiple medication
- Aged >80 yr
- Significantly underweight
- Congestive cardiac failure
- Abnormal liver function
- Receiving parenteral nutrition or drugs that potentiate warfarin significantly (see BNF Appendix 1)
Counsel patient
- Reason, risks and benefits of oral anticoagulation
- bleeding risk
- drug interactions (including alcohol)
- need for regular INR monitoring
- Provide anticoagulation information pack
Day 1
- Take blood for measurement of INR
- When INR result available:
- if INR ≤1.3 on day 1 and increased sensitivity to warfarin, choose Slow anticoagulation OATES regimen
- if INR <1.5 on day 1 and no factors likely to cause increased sensitivity to warfarin, choose Slow anticoagulation Tait regimen
- if INR fits neither of first two choices, seek senior advice
Slow anticoagulation OATES regimen
INR ≤1.3 on day 1 and increased sensitivity to warfarin
- Give warfarin 2 mg daily for first 7 days
Day 7
- Take next INR at day 7
- When INR result available, select:
- INR > 4.0 on day 7, choose dose intuitively. Seek senior advice
- If INR >5, consider overanticoagulation. See Warfarin overanticoagulation
- INR > 3.0-4.0 on day 7, give warfarin 1mg daily and move to Subsequent management
- INR≤ 3.0 on day 7, continue warfarin 2 mg daily until day 15
Day 15
Reminder: Only use for patient with INR≤ 3.0 on day 7 still on warfarin 2 mg daily
- Measure INR on day 15
When INR result available, select:
Enter Day 15 INR:
Slow anticoagulation Tait regimen
INR <1.5 on day 1 and no factors likely to cause increased sensitivity to warfarin
- Commence warfarin 5 mg daily starting on Monday, Thursday or Friday (day 1)
- but not on other days of the week
- Complete referral form for AMS
- Measure INR on days 5 and 8, and adjust daily dosage according to algorithm
- do not measure INR or adjust warfarin dosage on any other day as this will preclude use of the algorithm (unless patient’s clinical condition or medication alters)
- If INR outside parameters of algorithm, chose dose intuitively
- seek senior advice
Day 5 calculator
Enter Day 5 INR:
Day 8 Calculator
Enter Day 5 INR:
Enter Day 8 INR:
Subsequent management
- Make dose adjustments after end of initiation regimen intuitively
- watch for INR instability due to changing/starting/stopping of interacting medication or diet (see BNF appendix 1)
- If concerns of overcantioagulation, see Warfarin overanticoagulation
DISCHARGE
- Refer patients stabilised on warfarin to AMS for ongoing monitoring
- Order TTO for warfarin along with other medication
© 2022 The Bedside Clinical Guidelines Partnership.
Created by University Hospital North Midlands and Keele University School of Computing and Mathematics.
Research and development team: James Mitchell, Ed de Quincey, Charles Pantin, Naveed Mustfa