Continuation Of Therapy - Day 5 Forward

Target INR for patient who have completed Day 1-4 of the initiation protocol:
- 2.5-3.5 for patients with mechanical /prosthetic valves or recurrent thrombotic events.
- 2-3 for all other patients.
Adjust warfarin dose from day 5 forward based on INR response:

Medically stable patients without mechanical mitral valves or recurrent thrombotic events - target 2 to 3 (see Table 4):

Table 4. Adjusting Warfarin Dose for Days 5 forward for Medically Stable Patients Without Mechanical Mitral Valves or Recurrent Thrombotic Events

INR	Warfarin Adjustment
1.1-1.4	Increase dose by 20%
1.5-1.9	Increase dose by 10%
2-3	No change
3.1-3.5	Decrease dose by 10%
>3.5	Hold until INR <3.5; restart at 20% less than the previous dose

Mechanical /prosthetic mitral valves or recurrent thrombotic events - target 2.5 to 3.5 (see Table 5):

Table 5. Adjusting Warfarin Dose for Days 5 forward for Mechanical/Prosthetic Mitral Valves or Recurrent Thrombotic Events

INR	Warfarin Adjustment
1.1-1.4	Increase dose by 20%
1.5-2.4	Increase dose by 10%
2.5-3.5	No change
>3.5	Hold until INR <3.5; restart at 20% less than the previous dose

References

Ansell J, et al. Pharmacology and Management of the Vitamin K Antagonists: American College of Cheset Physicians Evidence-Based Clinical Practice Guidelines (8^th Edition). Chest. 133 (6Suppl): 160S-198S, 2008 Jun.

Bolton-Maggs P , Brook L. The use of vitamin K for reversal of over-warfarinization in children. Br J Haematol 2002; 118:924.

David, M., et al. Warfarin Therapy in Children. Thrombosis Interest Group of Canada. May 2004. http://www.tigc.org/eguidelines/warfarinchildren04.htm. Accessed 10/21/08.

Horton, JD, et al. Warfarin Therapy: Evolving Strategies in Anticoagulation. American Family Physician; 1999 Feb; 59(3):635-646. http://www.aafp.org/afp/AFPprinter/990201ap/635.html

Monagle P. Chalmers E. Chan A. DeVeber G. Kirkham F. Massicotte P. Michelson AD. Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). [Journal Article] Chest. 133(6 Suppl):887S-968S, 2008 Jun.

Monagle P. Chan A. Massicotte P. Chalmers E. Michelson AD. Antithrombotic therapy in children: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. [Review] [487 refs] [Guideline. Journal Article. Practice Guideline. Review] Chest. 126(3 Suppl):645S-687S, 2004 Sep.

Roach ES. Golomb MR. Adams R. Biller J. Daniels S. Deveber G. Ferriero D. Jones BV. Kirkham FJ. Scott RM. Smith ER. American Heart Association Stroke Council. Council on Cardiovascular Disease in the Young. Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. [Journal Article] Stroke. 39(9):2644-91, 2008 Sep.

These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.

Continuation Of Therapy - Day 5 Forward

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