Warfarin Protocol
Dr. MuKeSh M. DeSaI. M.D.
HaEmAtOlOgY & ImMuNoLoGy CeLl
Hematologist Oncologist & Immunologist:
B J Wadia Hospital for Children.
Sir H N Hospital.
B Nanavati Hospital.
Ref: Dr
Age: yrs.
Wt: kg
Ht: cms
Provisional Diagnosis:
3.4.
Risk Factor:
Rx Plan:
· Anticoagulation management for 6 mths.
· Recheck tests if Necessary
·
Investigation Plan:
·
Final Diagnosis:
Rx Strategy:
Warfarinisation
Principles of Warfarinisation
Anticoagulation in a patient with a Thrombotic event.
§ Start LMWH:
§ injection Clexane 0.8 to 1.0 mg / Kg OD or BiD
§ Or
§ Injection Fraxiparine 0.8 to 0.1 ml / 10 kg OD or BiD
§ Severe Renal failure requires modification of dosage of LMWH.
§ Rx with LMWH can be done on out patient basis if patient does not have below mentioned Risk factors
§ Symptomatic Pulmonary Embolism.
§ Severe Renal failure.
§ Severe thrombocytopenia or major bleeding risk
§ General principles of Monitoring LMWH
§ Start Warfarin 24 hrs after starting LM
§ Tab Warfarin 5 mg OD at 6.00 PM;
§ In Children dose of Warfarin is 0.1 to 0.2 mg/kg
§
§ Please note no loading dose
§ Measure PT/INR on day 5 and daily to maintain INR between 2.5 to 3.0
§ Target INR to be achieved and maintained at 2.5 to 3.0
§ Modification of dose of Warfarin depending on PT/INR on day 5 of warfarin.
§ If PT/INR > 3.0 decrease dose of Warfarin
§ If PT / INR < 2.5 increase dose of Warfarin
§ PT/INR testing frequency:
§ Weekly after each dosage change until 2 consecutive INRs are with in target range
§ Monthly thereafter as long as the INR remains in the target range.
§ As necessary when a medication is started or stopped that is documented to interact with Warfarin.
§ If a therapeutic range is to be maintained it is best to maintain INR in the middle region of that range.
§ Cease LMWH Clexane when the PT/INR has been greater than or equal to 2.5 on two consecutive days.
§ Please NOTE:
§ Length of Anticoagulation: 3 to6 mths / Life long.
§ Reevaluation: Repeat doppler after 3 to 6 mths.
Please do not hesitate to contact us in case u need any help
Please read about coumadin (Warfarin and you) before starting Rx.
NOTE:
In case patient needs any PLANNED surgery while on Anticoagulation with Warfarin following protocol is suggested:
§ IN CASE OF PLANNED SURGERY
§ Omit Warfarin on Date: # i.e. 4 days prior to surgery &
§ Start LMWH inj Clexane 40 mg OD
§ Measure PT/INR 1 day prior to surgery on date #
§ INR < 1.2
§ Patient fit for surgery
§ If PT / INR > 1.2;
§ INR < 1.2 Patient fit for surgery
§ STOP inj Clexane 24 hrs before surgery.
§ SURGERY
§ Restart inj LMWH Injection Clexane 0.6 ml SC BD 12 hrs post surgery
§ Restart oral Warfarin once patient started on oral feeds
§ Restart Warfarin 5 mg once daily.
§ Measure PT/INR after 4 day on day 5
§ If PT/INR > 3.0 decrease dose of Warfarin
§ If PT / INR < 2.5 increase dose of Warfarin
§ Target INR to be achieved and maintained at 2.5 to 3.0.
§ Cease LMWH Clexane when the PT/INR has been greater than or equal to 2.5 on two consecutive days.
§ Please NOTE:
§ Please watch for bleeding, bruises.
§ In case of bleeding STOP Warfarin immediately
§ CONSULT US IMMEDIATELY
§ OR CONTACT your family physician IMMEDIATELY.
§ Do URGENT PT/INR and contact.
In case patient needs Urgent Surgery following protocol is suggested:
§ IN CASE OF EMERGENCY SURGERY / LABOUR in Second / Third Trimester while patient on Warfarin
§ Omit Warfarin IMMEDIATELY
§ Measure PT/INR 1 IMMEDIATELY
§ INR < 1.2
§ Patient fit for surgery
§ If PT / INR > 1.2;
§ INR < 1.2 Patient fit for surgery / Induction of Labour
§ SURGERY / LSCS / Induction of Labour
§ Restart inj LMWH Injection Clexane 0.6 ml SC BD 12 hrs post surgery
§ Restart oral Warfarin once patient started on oral feeds
§ Restart Warfarin 5 mg once daily.
§ Measure PT/INR after 4 day on day 5
§ If PT/INR > 3.0 decrease dose of Warfarin
§ If PT / INR < 2.5 increase dose of Warfarin
§ Target INR to be achieved and maintained at 2.5 to 3.0.
§ Cease LMWH Clexane when the PT/INR has been greater than or equal to 2.5 on two consecutive days.
§ Please watch for bleeding, bruises.
Pregnancy & Anticoagulation:
§ IN CASE OF PLANNING A PREGNANCY PLEASE INFORM YOUR TREATING DOCTOR
§ ONCE PREGNANCY CONFIRMED
Management in First Trimester of Pregnancy.
§ Omit Warfarin IMMEDIATELY.
§ To prevent Warfarin Embryopathy.
§ Start LMWN
§ Inj Clexane 20 to 40 mg OD Subcutaneously.
§ Or
§ Inj Fraxiparine 0.8 to 0.1 ml/10 kg OD Subcutaneously.
§ LMWH to be continued till 12 weeks of gestation
§ LMWH started in view of its efficacy and safety profile.
§ Monitoring of LMWH
§ Anticoagulant effect
§ HIT
§
§ Management of Second and Third Trimester of Pregnancy.
§ Rewarfarinise patient as mentioned before.
§ Warfarin in Second and Third Trimester of Pregnancy is Safe
§ Warfarin Does NOT affect the fetus in Second Trimester.
§ Start Warfarin 5 mg once daily.
§ Take Warfarin at 6.00 pm in the evening.
§ Keep a constant Diet of vegetarian food.
§ Read about Warfarin and you before starting warfarin.
§ Measure PT/INR after 4 day on day 5
§ If PT/INR > 3.0 decrease dose of Warfarin
§ If PT / INR < 2.5 increase dose of Warfarin
§ Target INR to be achieved and maintained at 2.5 to 3.0.
§ Cease LMWH Clexane or Fraxiparine when the PT/INR has been greater than or equal to 2.5 on two consecutive days.
§ Monitoring of Warfarin
§ Monitor PT/INR initially weekly for 1 month.
§ Monitor PT/INR fortnightly for the entire course of pregnancy.
§ In case of Bleeding than to repeat PT/INR Urgently Immediately
§ Continue Warfarin till 36 weeks of gestation
§ OMIT warfarin and start LMWH Injection Clexane or Injection Fraxiparine as mentioned above.
§ Please watch for bleeding, bruises.
§ Management of Labour
§ IN CASE OF EMERGENCY LABOUR.
§ INR < 1.2
§ Patient fit for Labour / LSCS
§ Restart inj LMWH Injection Clexane 0.6 ml SC BD 12 hrs post Delivery
§ Restart oral Warfarin once patient started on oral feeds
§ Restart Warfarin 5 mg once daily.
§ Measure PT/INR after 4 day on day 5
§ If PT/INR > 3.0 decrease dose of Warfarin
§ If PT / INR < 2.5 increase dose of Warfarin
§ Target INR to be achieved and maintained at 2.5 to 3.0.
§ Cease LMWH Clexane when the PT/INR has been greater than or equal to 2.5 on two consecutive days.
§ IN CASE OF PLANNED LABOUR OR SURGERY
§ Omit LMWH 24 hrs prior to induction of Labour
§ Omit LMWH IMMEDIATELY
§ Injection Protamine of Not great help to revert effect of LMWH
§ Measure Coagulation Profile IMMEDIATELY
§ Keep FFP (Fresh Frozen Plasma) arranged in case of unexpected Bleed.
§ STOP inj Clexane 24 hrs before surgery.
§ SURGERY
§ Restart inj LMWH Injection Clexane 0.6 ml SC BD 12 hrs post surgery
§ Restart oral Warfarin once patient started on oral feeds
§ Restart Warfarin 5 mg once daily.
§ Measure PT/INR after 4 day on day 5
§ If PT/INR > 3.0 decrease dose of Warfarin
§ If PT / INR < 2.5 increase dose of Warfarin
§ Target INR to be achieved and maintained at 2.5 to 3.0.
§ Cease LMWH Clexane when the PT/INR has been greater than or equal to 2.5 on two consecutive days.
§ IN CASE OF EMERGENCY SURGERY / LABOUR in Second / Third Trimester while patient on Warfarin
§ Omit Warfarin IMMEDIATELY
§ Measure PT/INR 1 IMMEDIATELY
§ INR < 1.2
§ Patient fit for surgery
§ If PT / INR > 1.2;
§ INR < 1.2 Patient fit for surgery / Induction of Labour
§ SURGERY / LSCS / Induction of Labour
§ Restart inj LMWH Injection Clexane 0.6 ml SC BD 12 hrs post surgery
§ Restart oral Warfarin once patient started on oral feeds
§ Restart Warfarin 5 mg once daily.
§ Measure PT/INR after 4 day on day 5
§ If PT/INR > 3.0 decrease dose of Warfarin
§ If PT / INR < 2.5 increase dose of Warfarin
§ Target INR to be achieved and maintained at 2.5 to 3.0.
§ Cease LMWH Clexane when the PT/INR has been greater than or equal to 2.5 on two consecutive days.
§ Please watch for bleeding, bruises.