Warfarin Inpatient Nomogram including dose prediction
>Beta< Version 1.0
Other (used to predict maintenance dose):
Target INR: Patient receiving amiodarone:
DVT /PE present?:
Usual starting dose for most patients: 5 mg (Usual range:
4 -10 mg)
Select starting dose:
mg (Return to this form if
you need to alter the dose)
9th ACCP suggestion:
Patients healthy enough to be treated as outpatients:
Give warfarin 10 mg daily x 2 days. Further dosing
should be based on INR monitoring. (Preferred to
starting with an estimated maintenance dose.)
9th ACCP suggestion:
Patients with acute VTE should be started on warfarin
on day 1 or 2 of LMWH or heparin therapy e.g. do not
wait several days to start treatment. (Grade
9th ACCP suggestions:
-For pt's started on UFH: Use weight-adjusted
initial bolus of 80 units/kg followed by 18 units/kg
per hour for VTE; or bolus of 70 units/kg
followed by 15 units/kg per hour for cardiac
or stroke patients) or use of a fixed dose (bolus
5,000 units followed by 1,000 units/hour) rather than
alternative regimens (Grade 2C) .
-For outpatients with VTE treated with subcutaneous
UFH: use weight-adjusted dosing (first dose 333
units/kg, then 250 units/kg) without monitoring
rather than fixed or weight-adjusted dosing with
monitoring (Grade 2C) .
-For patients receiving therapeutic LMWH who have
severe renal-insufficiency (calculated CRCL <30
mL/min): Dose reduction is preferred rather than
using standard doses (Grade 2C) .
-Pt's with VTE and body weight > 100 kg: fondaparinux
treatment dose should be increased from the usual 7.5
mg to 10 mg daily SC (Grade 2C) .
Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J,
Kovacs MJ, Svensson PJ, Veenstra DL, Crowther M, Guyatt GH;
American College of Chest Physicians. Evidence-based
management of anticoagulant therapy: Antithrombotic Therapy
and Prevention of Thrombosis, 9th ed: American College of
Chest Physicians Evidence-Based Clinical Practice Guidelines.
Chest. 2012 Feb;141(2 Suppl):e152S-84S. doi:
(Weight) kg0.425 x (Height) cm0.725 x 0.007184 =
BSA in M2
DuBois D, DuBois DF. A formula to estimate the approximate surface area if
height and weight be known. Arch Int Med 1916;17:863-71.
Warfarin Dose Prediction
2] exp [0.613 + (0.425 x BSA) - (0.0075 x
age) + (0.156 x African-American race)
x target INR) - (0.257 x amiodarone) + (0.108 x smokes)
+ 0.0784 x DVT/PE ]Reference
: Gage BF, Eby C, Johnson JA, Deych E, Rieder MJ, et al.
Use of pharmacogenetic and clinical factors to predict the therapeutic
dose of warfarin. Clin Pharmacol Ther. 2008 Sep;84(3):326-31.