![]() Transitioning from rivaroxaban to warfarin: Some experts suggest overlapping rivaroxaban with warfarin for ≥2 days until INR is therapeutic. Discontinue the parenteral anticoagulant once a stable INR ≥2 is achieved continue warfarin. Parenteral option: Discontinue edoxaban and initiate a parenteral anticoagulant and warfarin at the time of the next scheduled edoxaban dose. Discontinue edoxaban once a stable INR ≥2 is achieved continue warfarin ( Ref). For patients taking edoxaban 30 mg once daily, reduce the dose to 15 mg once daily and begin warfarin concomitantly. Oral option: For patients taking edoxaban 60 mg once daily, reduce the dose to 30 mg once daily and begin warfarin concomitantly. Dabigatran is not recommended for use in patients with severe renal impairment. Myocardial infarction with left ventricular thrombus or high risk for left ventricular thrombus (eg, ejection fraction 50 mL/minute: Initiate warfarin 3 days before discontinuing dabigatran.ĬrCl 30 to 50 mL/minute: Initiate warfarin 2 days before discontinuing dabigatran.ĬrCl 15 to 30 mL/minute: Initiate warfarin 1 day before discontinuing dabigatran.ĬrCl <15 mL/minute: Dosing recommendations cannot be provided. Warfarin: Adult Target INR Ranges Based Upon Indication If patient considered to be at significant risk for bleeding, consider low-dose oral vitamin K.Decrease weekly maintenance dose by 5% to 20%.Hold until INR below upper limit of therapeutic range.A one-time supplemental dose of 7.5 mg may be considered on the day INR was checked, then start new maintenance dose (eg, 5 mg daily) the following day.Īdjustment(s) for subtherapeutic (low) INR – Note: If the factor causing subtherapeutic INR is transient (eg, missed warfarin dose or temporary change in vitamin K intake), consider resumption of prior maintenance dose following a one-time supplemental dose, if indicated. The weekly dose should be increased by 10% to 20% (eg, increase to 35 mg per week by administering 5 mg once daily). High-intensity anticoagulation: INR goal 2.5 to 3.5īAs an example, a patient with an INR goal of 2 to 3 and receiving 30 mg of warfarin per week (eg, administered as 5 mg on 5 days and 2.5 mg on 2 days) has an INR result of 1.4. ![]() Regular-intensity anticoagulation: INR goal 2 to 3 Example Warfarin Maintenance Dosing Nomogram a (Adapted From Hadlock 2018) In chronic therapy, INR values are most affected by the doses administered 2 to 3 days prior to INR measurement. INR should be checked at least weekly when it is out of range and approximately every 4 weeks once therapeutic and stable. Once INR is therapeutic and stable following initiation, subsequent dosage requirements may be guided with the use of a maintenance dosing nomogram (see example warfarin maintenance dosing nomogram below). Maintenance: Usual maintenance dose: 2 to 10 mg once daily. However, this nomogram has not been validated for starting doses >5 mg/day. A higher initial dose may also be appropriate in a patient who was previously treated with warfarin and required high doses or is receiving a medication that increases warfarin metabolism. Reduced dosing for patients expected to be more sensitive to warfarin cĭ Young, healthy patients may start at 7.5 or 10 mg for the first 2 days (ACCP ). Standard dosing for patients who are not expected to be sensitive to warfarin b Example Warfarin Initiation Nomogram Targeting an INR Range of 2 to 3 (for Outpatients or Clinically Stable Inpatients) (Adapted From Wittkowsky 2018) a Accordingly, in patients at high risk for thromboembolism, overlap ("bridging") with a parenteral anticoagulant may be necessary during initiation of warfarin until a stable therapeutic INR is attained ( Ref). Although an elevation in INR can be seen as soon as 24 to 48 hours after the first dose due to depletion of factor VII, this does not represent therapeutic anticoagulation because other vitamin K–dependent clotting factors with longer half-lives (eg, factors II, IX, and X) must also be depleted. A lower or higher starting dose may be used depending upon patient-specific factors (see example warfarin initiation nomogram below). Initial: 5 mg once daily for most patients.
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