✓  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: