Part One: Warfarin Dosing Guidelines

Warfarin: Dosing & Monitoring

Start low

• Initiate 5 mg daily*

• Educate patient

 

Stabilize

• Titrate to appropriate INR

• Monitor INR frequently (daily then weekly)

 

Adjust as necessary

• Monitor INR regularly (every 1–4 weeks) and adjust

* Elderly, frail, liver disease, malnourished:  2 mg/day

Notes:

This slide provides guidelines for safe and effective warfarin use. The dose of warfarin should be monitored daily until the INR is in the therapeutic range and then  less frequently when a stable dose-response relationship is achieved. Regardless of the degree of stability in warfarin dosing and INR value in the hospital, it is important to monitor the INR frequently post hospital discharge (i.e., at least 1–3 days after discharge) and to spread out the interval of monitoring thereafter depending on INR response. Monitoring is necessary in all patients, but can be reduced to four weekly intervals in the low risk (for bleeding) patient who shows a stable dose-response.

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