Determine need for warfarin hold, and LMWH or UFH bridge if warfarin hold is warranted:
Obtain labs and write prescriptions:
- Use your clinical judgment to assess risks versus benefits of holding warfarin.
- In general, for procedures requiring warfarin hold <3 days, bridging may not be necessary as the INR is not expected to reach baseline (1.0).
- For procedures requiring ≥5 days of warfarin hold, consider +/- bridge based on an individual patient’s indication for anticoagulation. See individual procedure recommendations below.
Provide your patient with explicit peri-procedural instructions.
- Check INR within 1-2 weeks of warfarin hold:
- INR <1.7: consider shorter warfarin hold or longer LMWH/ UFH bridgeINR
- INR 1.8-3.9: general recommendations
- INR >4.0: consider longer warfarin hold and post-op warfarin dose adjustment
- If planning to bridge, a serum creatinine is needed so that Creatinine Clearance can be calculated:
- CrCl <30mL/min: Enoxaparin contraindicated, use UFH or dalteparin
- CrCl 30-40mL/ min: Consider prophylactic (i.e., 30-40mg) dose of enoxaparin or use dalteparin
- CrCl >40mL/ min: No adjustment in enoxaparin dose needed
- Choose an appropriate LMWH or UFH dose and send in prescription:
- PA may be required (add 3-5 days)
- LMWH and UFH may not be in stock at community pharmacy (add 1-2 days)
- UCSD pharmacies keep all doses in stock and are can quickly obtain necessary authorizations (often no delay in getting med to patient)
Use sample calendar instructions to further clarify details of warfarin and heparin/LMWH dosing: