Adjustment Guidelines
A: Baseline CBC, PT/INR required prior to continuation of warfarin therapy.
B: Assess patient compliance and determine if any changes have been made that may impact therapy: 1) addition of interacting drugs or herbal products; 2) changes in diet (eating/not eating) 3) changes in health status.
C: Based on the INR results make adjustments to the current therapy based on the ranges below:
———————————————————————–
INR < 1.5
———————————————————————–
1.) Verify compliance (if non-compliant: resume therapy at previous dose).
2.) If dosage adjustment needed: increase maintenance dose by 5%- 20%*.
[* Some clinicians recommend a ‘booster dose’ 1.5 to 2x the daily maintenance dose x 1 ]
3.) Return: 3 – 7 days
———————————————————————–
INR 1.5 – 1.9
———————————————————————–
1.) Verify compliance (if non-compliant: resume therapy at previous dose).
2.) [* Some clinicians recommend a ‘booster dose’ 1.5 to 2x the daily maintenance dose x 1 ]
3.) If dosage adjustment needed: increase maintenance dose by 5 – 15% (use lower end of this range for INR values close to the therapeutic range).
4.) Return: 3 – 7 days
———————————————————————–
INR 2.0 – 3.0
———————————————————————–
1.) No Changes Needed
2.) Return: 4 weeks
———————————————————————–
INR 3.1 – 3.4
———————————————————————–
1.) Dose adjustment usually not necessary if level is at the low end of this range ( 3.1 – 3.2) and at least two previous levels were therapeutic. Recheck in 3 to 7 days.
2.) Consider decreasing dose by 5 – 10% and/or holding one dose.
3.) Recheck in 3- 7 days.
———————————————————————–
INR 3.5 – 3.9
———————————————————————–
1.) consider holding one dose.
2.) evaluate any clinical changes that may have occurred with the patient (eating regularly, no new medications, etc.)
3.) consider decreasing the maintenance dose by 5 -15% depending on magnitude of the INR elevation.
4.) Return: 1- 3 days.
———————————————————————–
INR 4.0 – 4.9 with no significant bleeding
———————————————————————–
1.) Hold warfarin until INR is within the therapeutic range.
2.) Recommend lowering maintenance dose by 5%- 20%
3.) Increase frequency of monitoring until problem resolved (daily initially).
4.) (8th ACCP): If only minimally above therapeutic range or associated with a transient causative factor, no dose reduction may be required.
———————————————————————–
INR > 5.0
———————————————————————–
1.) Review 8th ACCP guidelines – ELEVATED INRs.
2.) Return daily until therapeutic.
