Pre-Procedure

✓  Determine need for warfarin hold, and LMWH or UFH bridge if warfarin hold is warranted:

• 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.

✓ Obtain labs and write prescriptions:

• 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)

✓ Provide your patient with explicit peri-procedural instructions.

• Establish exact days to stop and restart warfarin.
• Use a calendar to further clarify details of warfarin and heparin dosing for your patient.
• Teach your patient how to administer subcutaneous injections .
• Have a follow-up plan and schedule the next INR draw.

Patient Instructions

Use sample calendar instructions to further clarify details of warfarin and heparin/LMWH dosing:

• Patient calendar - Sample 1
• Patient calendar - Sample 2