warfarin maintenance dosing nomogram - 2014

Warfarin maintenance dosing nomogramPublished on Anticoagulation Services(http://depts.washington.edu/anticoag/home)

Warfarin maintenance dosing nomogram Guidelines for warfarin maintenance dosing adjustments

For Goal INR 2-3 Dosing Adjustments For Goal INR 2.5-3.5

INR < 1.5 consider a booster doseof 1 ½ -2 times dailymaintenance doseconsider resumption ofprior maintenance doseif factor causingdecreased INR istransient [eg: missedwarfarin dose(s)]if adosage adjustment isneeded, increasemaintenance dose by10%–20%

INR < 2.0

INR 1.5-1.7 consider a booster doseof 1 ½ – 2 times dailymaintenance doseconsider resumption ofprior maintenance doseif factor causingdecreased INR isconsidered [eg: missedwarfarin dose(s)]if a dosage adjustment isneeded, increasemaintenance dose by5-15%

INR 2.0–2.3

INR 1.8–1.9 no dosage adjustmentmay be necessary if thelast two INRs were inrange, if there is no clearexplanation for the INRto be out of range, and ifin the judgment of theclinician, the INR doesnot represent anincreased risk ofthromboembolism for thepatientconsider a booster doseof 1 ½ – 2 times dailymaintenance doseconsider resumption ofprior maintenance doseif factor causingdecreased INR istransient [eg: missedwarfarin dose(s)]if a dosage adjustment isneeded, increase

INR 2.3–2.4

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Warfarin maintenance dosing nomogramPublished on Anticoagulation Services(http://depts.washington.edu/anticoag/home)

maintenance dose by5%–10%

2.0-3.0 Desired range 2.5-3.53.1-3.2 no dosage adjustment

may be necessary if thelast two INRs were inrange, if there is no clearexplanation for the INRto be out of range, and ifin the judgment of theclinician, the INR does norepresent an increasedrisk of hemorrhage forthe patientconsider continuation ofprior maintenance doseif factor causing elevatedINR is transient [eg:acute alcohol ingestion]if a dosage adjustment isneeded, decreasemaintenance dose by5%–10%

3.6-3.7

3.3-3.4 consider holding ½ to 1doseconsider resumption ofprior maintenance doseif factor causing elevatedINR is transient [eg:acute alcohol ingestion]if a dosage adjustment isneeded, decreasemaintenance dose by5%–10%

3.8-3.9

3.5-3.9 consider holding 1 doseConsider resumption ofprior maintenance doseif factor causing elevatedINR is transient [eg:acute alcohol ingestion]if a dosage adjustment isneeded, decreasemaintenance dose by5%–15%

4.0-4.4

> 4.0 Hold until INR < upperlimit of therapeutic rangeConsider use of minidoseoral vitamin KConsider resumption ofprior maintenance doseif factor causing elevatedINR is transient [eg:acute alcohol ingestion]if a dosage adjustment isneeded, decreasemaintenance dose by5%–15%

> 4.5

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Warfarin maintenance dosing nomogramPublished on Anticoagulation Services(http://depts.washington.edu/anticoag/home)

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