Download warfarin target inr 2.5-3.5

The Warfarin Order Sheet has been approved by the P & T committee to be implemented by pharmacists.
These orders are not used to treat patients with serious hemorrhagic complications.
WARFARIN TARGET INR 2.5-3.5
PATIENT NAME:___________________________________ DIAGNOSIS:_________________________________________
WEIGHT:___________kg HEIGHT:___________cm ALLERGIES:______________________________________________
INR Range
Target INR
Indications:  Mechanical prosthetic valves (high risk)
2.5-3.5
3
________
________
 Other________________________________
Hematology
Consult:
Notify LIP
Laboratory
Tests:




Patient is receiving other medications that can affect warfarin.
Patient has liver disease, protein C deficiency or Fontan.
Patient is an infant
Other_____________________________________________
 Concerns for bleeding: guaiac positive, drop in platelet count or HgB, headache or change in neuro exam
 Patient starting therapy:
 Prior to first dose obtain:
 PT/INR
 CBC
 Beta HCG for females greater than or equal to 12 years of age or post-menarche.
 INR every morning.
 CBC every 3 days.
 Patient is on maintenance therapy:
 INR if the patient is on warfarin when admitted and an INR has not been drawn in the last week.
 INR weekly if patient is stabilized at goal INR: most recent INR _________ Date_________
 RPh will refer to the dosing nomogram below to calculate and document warfarin dose on Patient Order
Dosing:
Form each day for administration at 2000.
 Continue patient’s therapeutic home dose of ____________________________ mg PO daily at 2000.
Loading dose
 Initial loading dose: __________ mg (0.2 mg/kg) warfarin (max dose 10 mg) PO daily at 2000.
 Liver disease or protein C deficiency: Initial loading dose: _________ mg (0.1 mg/kg) warfarin (max
dose 5 mg) PO daily at 2000.
 Other initial loading dose: ___________ mg warfarin (max dose 10 mg) PO daily at 2000.
 Warfarin anticoagulation therapy to be managed and orders written by patient’s physician/LIP according to
the Anticoagulation Policy and warfarin guideline.
Ongoing dosing and labs to be ordered by pharmacy according to nomogram.
INITIAL DOSING (days 2-4) for goal INR 2.5-3.5
INR
1.1-1.5
1.6-2.4
2.5-3.5
3.6-4.5
Greater than 4.6
Dosing
Repeat initial dose and (consider bridge
therapy)
Give 50% of initial dose
Give 25% of initial dose
Give 10% of initial dose
Hold dose until INR less than 4, then restart
at 20% less than previous dose
Contact LIP for INR greater than 4 for longer than two days
MAINTENANCE DOSING (5 days or more ) for goal INR
2.5-3.5
INR
Dosing
1.1 – 1.6
Consider bridging with LMWH or UFH
1.7-2
2.1-2.4
2.5-3.5
Increase daily dose by 20%
Increase daily dose by 10%
Continue current dose
3.6-4
Decrease daily dose by 10%
4.1-4.5
One dose at 50% less/decrease daily dose by
20%
4.6-5
Greater than 5
Hold 1 dose. Restart at 20% less than
previous daily dose
Hold dose until INR < 3.5, and contact
Hematology service
Signature: _____________________________________________ (MD/LIP) Date: _____________ Time: _____________
Print Name: ________________________________________
Signature: _______________________________________ (RN)
Date: _____________ Time: _____________
Signature: _______________________________________ (HUC) Date: _____________ Time: _____________
WARFARIN GUIDELINE TARGET INR 2.5-3.5 (Page 1 of 2)
PHA313 (05/2012) Rev; 09/2015
WARFARIN GUIDELINE TARGET INR 2.5-3.5
PEDIATRIC
TREATMENT OR PROPHYLAXIS FOR
 Mechanical prosthetic valves (high risk)
 Other
CONTRAINDICATIONS (Consider Hematology Consult)
 Active bleeding or significant bleeding within the last 24 hours
 INR greater than 2
 Received thrombolytic therapy within the last 12 hours
 Known or suspected hemorrhagic stroke
 Monotherapy with recently diagnosed HIT
 Hematuria






Hemorrhagic disorders
Epidural anesthesia
Active TB (use with caution)
Pregnancy (teratogenic)
Hypersensitivity to warfarin
Risk for intracranial/intraocular hemorrhage
NOTIFY LIP if the patient develops any of the following:
 Bleeding or positive stool guaiac
 INR greater than 4 for two days
 Platelet count less than 100,000/cumm or 2-gram drop in Hgb
 Unusual headache or change in neurological exam
 Interacting Medications
DAILY CARE
 Consider discontinuing aspirin containing products and anti-inflammatory medications (NSAIDS).
 No intramuscular injections.
 Avoid unnecessary venous or arterial punctures.
 Guaiac stools that appear black, tarry, or contain frank blood.
 No vitamin K supplements or foods rich in vitamin K (dietary to be alerted of patients on warfarin).
BRIDGING GUIDELINE
Medication
Enoxaparin
Warfarin
How long to hold
prior to procedure
12 hours
2-5 days
Goal INR less than 1.4
Aspirin
Heparin
Clopidogrel
Rivaroxaban
7 days
4-6 hours
Goal Anti Xa less than 0.35
5-7 days
24 hours
LABS
 Prior to first dose draw (if not within last 24 hours) PTT, PT/INR, fibrinogen and CBC. Draw a Beta HCG for
females older than 12 yr or post-menarche.
 Draw an INR if the patient is on warfarin when admitted and an INR has not been drawn in the last week.
 Draw an INR every morning until stable for 2 days and then weekly.
 Draw a CBC every three days for two weeks then weekly.
 Increase frequency of monitoring with evidence of bleeding
Dosage and Administration of Warfarin
 If initial labs are appropriate, order a 0.2 mg/kg dose of warfarin (max dose 10 mg) to be given at 2000.
 Consider hematology consult for possible dose adjustments if:
o Patient is receiving other medications that interact with warfarin.
o Patient has underlying liver dysfunction – consider 0.1mg/kg (max dose 5 mg).
o If unable to achieve therapeutic levels consider switching to low molecular weight heparin.
 Once INR is therapeutic, calculate the average daily dose by summing the total loading dose (up to 7
days) and dividing by the number of days needed to load
CONVERSION TO ORAL ANTICOAGULANT THERAPY: Continue enoxaparin/heparin for at least five days in
combination with warfarin therapy. Ensure INR is therapeutic for at least two days prior to stopping Enoxaparin/heparin.
These are intended to be a guide to common clinical circumstances, and may not apply to certain patients and situations.
The treating clinician must use judgment in application of guidelines to the care of individual patients.
WARFARIN GUIDELINE TARGET INR 2.5-3.5 (Page 2 of 2)
PHA313 (05/2012) Rev; 09/2015