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May 15 pointofcare.pdf

Figure 1. Warfarin Dose Reminder Chart
Your doctor has highlighted a row below showing the total amount of warfarin (Coumadin) you should take each week. Look at the highlighted row and find the number under today’s day of the week. Take that number of 5-mg warfarin tablets at approximately 5 p.m. Number of 5-mg tablets to take on each day of the week
NOTE TO THE PHYSICIAN: The initial total weekly dose (first column) can be derived using the nomogram published in: Ebell MH. Evidence-based initiation of warfarin (Coumadin). Am Fam Physician 2005;71:763-5; available online at: Chart developed by Mark H. Ebell, MD, MS, Michigan State University College of Human Medicine, East Lansing. Copyright 2005 American Academy of Family Physicians. Physicians may photocopy or adapt for use in their own practices; all other rights reserved. “Point-of-care Guides.” Ebell MH. American Family Physician. May 15, 2005;71:1979-82. Accessible online at: treatment compared with primary care management. J Clin Pathol 6. Dalere GM, Coleman RW, Lum BL. A graphic nomogram for warfarin dosage adjustment. Pharmacotherapy 1999;, and one and 5. Ansell J, Holden A, Knapic N. Patient self-management of oral antico- one half 5-mg tablets on Monday and Friday). Her INR today is 3.6. agulation guided by capil ary (fingerstick) whole blood prothrombin Looking back, her INR trend was gradual y upward; her last value was times. Arch Intern Med 1989;149:2509-11.
2.9. How should you adjust her warfarin dose? 1980 American Family Physician
Volume 71, Number 10May 15, 2005 Outpatient Anticoagulation Flowsheet
Patient’s name: Date of birth: / / Medical record #: Indication for anticoagulation (check one): ❏ Atrial fibril ation Target International Normalized Ratio (INR)*: ❏ 2.0 to 3.0 ❏ 2.5 to 3.5 ❏ Other: Start date: / / Therapy duration: ❏ 3 months ❏ 6 months ❏ 1 year ❏ Indefinite ❏ Other: Dosage Adjustment Algorithms
For target INR of 2.0 to 3.0, no bleeding*: Increase dose 10 to 20%; Increase dose No change For target INR of 2.5 to 3.5, no bleeding*: Increase dose 10 to 20%; Increase dose No change *—See reverse side for further guidance.
—If INR is 1.8 to 1.9 or 3.1 to 3.2, consider no change with repeat INR in seven to 14 days.
—For example, if a patient has had three consecutive in-range INR values, recheck in 3 weeks.
§—If INR is 2.3 to 2.4 or 3.6 to 3.7, consider no change with repeat INR in seven to 14 days. Outpatient Anticoagulation Flowsheet (continued)
Anticoagulation Decision Support
DVT or PE1
then warfarin (Coumadin); treat until cancer is resolved* First episode, antiphospholipid antibodies or at least two risk factors† Atrial fibrillation2
Valvular disease3
Rheumatic mitral valve and atrial fibril ation or previous emboli
Rheumatic mitral valve disease, normal sinus rhythm, and left atrial Mitral tilting disk valves and bileaflet mechanical valves Aortic CarboMedics bileaflet or Medtronic Hall tilting disk valves, Mechanical valves with risk factors (atrial fibril ation, myocardial infarction, LAE, endocardial damage, low ejection fraction) Mechanical valve with breakthrough embolism despite INR 2.0 to 3.0 Management of Significantly Elevated INR With or Without Bleeding4
INR 5.0 to 8.9, no significant bleeding: Omit 1 to 2 doses; reduce dose 10 to 20 percent; monitor frequently. Alternatively
consider vitamin K1 1.0 to 2.5 mg oral y.
INR ≥ 9.0, no significant bleeding: Hold warfarin therapy; give vitamin K1 5.0 to 10 mg oral y; monitor frequently. Resume at Serious bleeding, any INR: Hold warfarin; give vitamin K1 10 mg slow IV plus fresh plasma or prothrombin complex concentrate, depending on urgency; repeat vitamin K1 every 12 hours as needed.
Life-threatening bleeding, any INR: Hold warfarin; give prothrombin complex concentrate (or recombinant factor VIIa as an alternative) supplemented with vitamin K1 (10 mg slow IV); repeat as needed.
INR = International Normalized Ratio; SORT = Strength-of-Recommendation Taxonomy; DVT = deep venous thrombosis; PE = pulmonary embolism; LMWH = low-molecular-weight heparin; LAE = left atrial enlargement; IV = intravenous. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series. *—Consider indefinite therapy for selected patients.
—Deficiency of antithrombin III, protein C, or protein S; prothrombotic gene mutation such as V Leiden or prothrombin 20210; homocystinemia, or factor VIII levels above the 90th percentile of normal; or persistent residual thrombosis on repeated testing with compression ultrasonography.
—Not indicated in patients younger than 65 years who do not have risk factors (i.e., heart failure, hypertension, previous ischemic stroke or transient ischemic attack, or diabetes mel itus). 1. Bul er HR, Agnel i G, Hull RD, Hyers TM, Prins MH, Raskob GE. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy [published correction appears in Chest 2005;127:416]. Chest 2004;126(3 suppl):401S-428S. 2. Singer DE, Albers GW, Dalen JE, Go AS, Halperin JL, Manning WJ. Antithrombotic therapy in atrial fibril ation: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 suppl):429S-456S. 3. Salem DN, Stein PD, Al-Ahmad A, Bussey HI, Horstkotte D, Mil er N, et al. Antithrombotic therapy in valvular heart disease – native and prosthetic: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 suppl):457S-482S. 4. Ansell J, Hirsh J, Poller L, Bussey H, Jacobson A, Hylek E. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy [published correction appears in Chest 2005;127:415-6]. Chest 2004;126(3 suppl):204S-233S.



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