If the patient was previously stable on warfarin and presents with an isolated INR of 0.5 or less above or below therapeutic range, the current dosage should be continued and the patient retested in one to two weeks (grade 2C)
Patients at high risk of bleeding may be better suited for traditional dosingĬaution: check INR after two or three doses Helps to achieve therapeutic INR sooner and decreases the number of LMWH doses needed
Warfarin therapy at 10 mg daily for two days may be initiated in healthy outpatients with acute thromboembolism (grade 2C) Revised recommendations for treatment of patients with supratherapeutic INRs who do not have significant bleedingįor patients with an INR between 4.5 and 10, routine use of vitamin K is not recommended (grade 2B)įor patients with an INR greater than 10 without significant bleeding, oral vitamin K is recommended (grade 2C)Īdvocating more judicious and conservative use of vitamin K Outpatients with solid tumors, additional risk factors for deep venous thrombosis, and low bleeding risk should receive prophylactic doses of LMWH (grade 2B) Simplification of anticoagulation management: no need for frequent dosage adjustments, INR monitoring Recommended over warfarin (Coumadin) in patients with nonvalvular atrial fibrillation who do not have severe renal impairment (grade 2B) In patients with atrial fibrillation and at least one other risk factor for stroke, newer agents (rivaroxaban and dabigatran ) that do not require frequent laboratory monitoring are as effective as warfarin for prevention of stroke or systemic embolism and have comparable risks of major bleeding.Ĭompared with usual clinic-based care, patient self-testing for international normalized ratios, with or without self-dosing of warfarin, is associated with significantly fewer deaths and thromboembolic complications without any increase in bleeding complications for a selected group of motivated patients who have completed appropriate training. Health care professionals skilled in the initiation and assessment of therapy and dosing adjustments can dramatically influence outcomes. Patients taking warfarin (Coumadin) should be treated using systematic processes of care to optimize effectiveness and minimize adverse effects. Rivaroxaban is indicated for the prevention of deep venous thrombosis in patients undergoing knee or hip replacement surgery, for treatment of deep venous thrombosis and pulmonary embolism, for reducing the risk of recurrent deep venous thrombosis and pulmonary embolism after initial treatment, and for prevention of systemic embolism in patients with nonvalvular atrial fibrillation. Dabigatran and apixaban are indicated for the prevention of systemic embolism and stroke in persons with nonvalvular atrial fibrillation. Food and Drug Administration since publication of the eighth edition in 2008. The ninth edition of the American College of Chest Physicians guidelines, published in 2012, includes a discussion of anticoagulants that have gained approval from the U.S. Increasingly, self-testing is an option for selected patients on warfarin therapy. Bridging with low-molecular-weight heparin or other agents is based on balancing the risk of thromboembolism with the risk of bleeding. Warfarin therapy should be stopped five days before major surgery and restarted 12 to 24 hours postoperatively. The international normalized ratio goal and duration of treatment with warfarin vary depending on indication and risk. The heparin product or fondaparinux should be continued for at least five days and until the patient's international normalized ratio is at least 2.0 for two consecutive days. When warfarin therapy is initiated for venous thromboembolism, it should be given the first day, along with a heparin product or fondaparinux. Warfarin, a vitamin K antagonist, is recommended for the treatment of venous thromboembolism and for the prevention of stroke in persons with atrial fibrillation, atrial flutter, or valvular heart disease. The American College of Chest Physicians provides recommendations for the use of anticoagulant medications for several indications that are important in the primary care setting.
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