Point-of-Care Guides - May 15, 2005 - American Family Physician

Point-of-Care Guides

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Figure 1. Warfarin Dose Reminder Chart

Name: ________________________________ Date of adjustment: ____/____/____

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

Total weekly dose (mg)	Number of tablets on Monday	Number of tablets of Tuesday	Number of tablets on Wednesday	Number of tablets on Thursday	Number of tablets on Friday	Number of tablets on Saturday	Number of tablets on Sunday
2.5	1/2	0	0	0	0	0	0
5.0	1/2	0	0	0	1/2	0	0
7.5	1/2	0	1/2	0	1/2	0	0
10.0	1/2	0	1/2	0	1/2	0	1/2
12.5	1/2	0	1/2	0	1/2	1/2	1/2
15.0	1/2	0	1/2	1/2	1/2	1/2	1/2
17.5	1/2	1/2	1/2	1/2	1/2	1/2	1/2
20.0	1	1/2	1/2	1/2	1/2	1/2	1/2
22.5	1	1/2	1/2	1/2	1	1/2	1/2
25.0	1	1/2	1	1/2	1	1/2	1/2
27.5	1/2	1	1/2	1	1/2	1	1
30.0	1/2	1	1	1	1/2	1	1
32.5	1/2	1	1	1	1	1	1
35.0	1	1	1	1	1	1	1
37.5	1 1/2	1	1	1	1	1	1
40.0	1 1/2	1	1	1	1 1/2	1	1
42.5	1 1/2	1	1 1/2	1	1 1/2	1	1
45.0	1	1 1/2	1	1 1/2	1	1 1/2	1 1/2
47.5	1	1 1/2	1 1/2	1 1/2	1	1 1/2	1 1/2
50.0	1	1 1/2	1 1/2	1 1/2	1 1/2	1 1/2	1 1/2
52.5	1 1/2	1 1/2	1 1/2	1 1/2	1 1/2	1 1/2	1 1/2
55.0	2	1 1/2	1 1/2	1 1/2	1 1/2	1 1/2	1 1/2
57.5	2	1 1/2	1 1/2	1 1/2	2	1 1/2	1 1/2
60.0	2	1 1/2	2	1 1/2	2	1 1/2	1 1/2
62.5	1 1/2	2	1 1/2	2	1 1/2	2	2
65.0	1 1/2	2	2	2	1 1/2	2	2
67.5	1 1/2	2	2	2	2	2	2
70.0	2	2	2	2	2	2	2

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: http://www.aafp.org/afp/20050215/poc.html.

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: http://www.aafp.org/afp/20050515/pocform.html.

Outpatient Anticoagulation Flowsheet

Patient's name: ____________ Date of birth: ____/____ /____ Medical record #: ________

Indication for anticoagulation (check one):	Atrial fibrillation	Deep venous thrombosis	Pulmonary embolism
Indication for anticoagulation (check one):	Mechanical valve	Cerebrovascular accident	Other

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:_____________

Date	Current dose	INR	Complications	New dose	Next INR	Initials

Dosage Adjustment Algorithms
For target INR of 2.0 to 3.0, no bleeding*:
INR	< 1.5	1.5 to 1.9	2.0 to 3.0	3.1 to 3.9	4.0 to 4.9	>= 5.0
Adjustment	Increase dose 10 to 20%; consider extra dose	Increase dose 5 to 10%†	No change	Decrease dose 5 to 10%†	Hold for 0 to 1 day then decrease dose 10%	See reverse side.
Next INR	4 to 8 days	7 to 14 days	No. of consecutive in-range INRs x 1 wk (max: 4 wks)‡	7 to 14 days	4 to 8 days	See reverse side.
For target INR of 2.5 to 3.5, no bleeding*:
INR	< 1.5	1.5 to 2.4	2.5 to 3.5	3.6 to 4.5	4.5 to 6.0	> 6.0
Adjustment	Increase dose 10 to 20%; consider extra dose	Increase dose 5 to 10%§	No change	Decrease dose 5 to 10%; consider holding one dose§	Hold for 1 to 2 days then decrease dose 5 to 15%	See reverse side.
Next INR	4 to 8 days	7 to 14 days	No. of consecutive in-range INRs x 1 wk (max: 4 wks)‡	7 to 14 days	2 to 8 days	See reverse side.
*-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.

Anticoagulation Decision Support

Indication

Target INR

Duration of therapy

SORT

DVT or PE1

First episode, transient risk factor

2.0 to 3.0

3 months

First episode, idiopathic DVT

2.0 to 3.0

6 to 12 months*

First episode, patient with cancer

2.0 to 3.0

LMWH for 3 to 6 months, then warfarin (Coumadin); treat until cancer is resolved*

First episode and single risk factor†

2.0 to 3.0

6 to 12 months*

First episode, antiphospholipid antibodies or at least two risk factors†

2.0 to 3.0

12 months*

Recurrent DVT

2.0 to 3.0

Indefinitely

Atrial fibrillation2

2.0 to 3.0

Indefinitely‡

Valvular disease3

Rheumatic mitral valve and atrial fibrillation or previous emboli

2.0 to 3.0

Indefinitely

Rheumatic mitral valve disease, normal sinus rhythm, and left atrial diameter > 5.5 cm

2.0 to 3.0

Indefinitely

Aortic St. Jude Medical bileaflet valve

2.0 to 3.0

Indefinitely

Mitral tilting disk valves and bileaflet mechanical valves

2.5 to 3.5

Indefinitely

Aortic CarboMedics bileaflet or Medtronic Hall tilting disk valves,
normal sinus rhythm, and no LAE

2.0 to 3.0

Indefinitely

Mechanical valves with risk factors (atrial fibrillation, myocardial
infarction, LAE, endocardial damage, low ejection fraction)

2.5 to 3.5

Indefinitely,* low-dose aspirin

Caged ball or disk valve

2.5 to 3.5

Indefinitely,* low-dose aspirin

Mechanical valve with breakthrough embolism despite INR 2.0 to 3.0

2.5 to 3.5

Indefinitely,* low-dose aspirin

Bioprosthetic valve (mitral)

2.0 to 3.0

3 months after placement

Bioprosthetic valve (aortic)

2.0 to 3.0

3 months of warfarin or aspirin

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 orally.

INR >= 9.0, no significant bleeding: Hold warfarin therapy; give vitamin K1 5.0 to 10 mg orally; monitor frequently. Resume at lower dose when INR is therapeutic.

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 comlex 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 mellitus).

1. Buller HR, Agnelli 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 fibrillation: 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, Miller 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.

Copyright © 2005 by the American Academy of Family Physicians.
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