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