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Warfarin Maintenance Dosing Adjustment Nomogram for INR Goal of 2-3
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Adjustment Guidelines
A: Baseline CBC, PT/INR required prior to continuation of warfarin therapy.
B: Assess patient compliance and determine if any changes have been made that may impact therapy: 1) addition of interacting drugs or herbal products; 2) changes in diet (eating/not eating) 3) changes in health status.
C: Based on the INR results make adjustments to the current therapy based on the ranges below:

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INR < 1.5
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1.)  Verify compliance (if non-compliant: resume therapy at previous dose).
2.)  If dosage adjustment needed: increase maintenance dose by 5%- 20%*.
   [* Some clinicians recommend a 'booster dose' 1.5 to 2x the daily maintenance dose x 1 ]
3.)  Return: 3 – 7 days

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INR 1.5 - 1.9
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1.)  Verify compliance (if non-compliant: resume therapy at previous dose).
2.)  [* Some clinicians recommend a 'booster dose' 1.5 to 2x the daily maintenance dose x 1 ]
3.)  If dosage adjustment needed: increase maintenance dose by 5 - 15% (use lower end of this range for INR values close to the therapeutic range).
4.)  Return: 3 – 7 days

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INR 2.0 - 3.0
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1.)  No Changes Needed
2.)  Return: 4 weeks

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INR 3.1 - 3.4
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1.)  Dose adjustment usually not necessary if level is at the low end of this range ( 3.1 – 3.2) and at least two previous levels were therapeutic. Recheck in 3 to 7 days.
2.)  Consider decreasing dose by 5 - 10% and/or holding one dose.
3.)  Recheck in 3- 7 days.

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INR 3.5 - 3.9
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1.)  consider holding one dose.
2.)  evaluate any clinical changes that may have occurred with the patient (eating regularly, no new medications, etc.)
3.)  consider decreasing the maintenance dose by 5 -15% depending on magnitude of the INR elevation.
4.)  Return: 1- 3 days.

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INR 4.0 - 4.9 with no significant bleeding
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1.)  Hold warfarin until INR is within the therapeutic range.
2.)  Recommend lowering maintenance dose by 5%- 20%
3.)  Increase frequency of monitoring until problem resolved (daily initially).
4.)  (8th ACCP): If only minimally above therapeutic range or associated with a transient causative factor, no dose reduction may be required.

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INR > 5.0
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1.) Review 8th ACCP guidelines - ELEVATED INRs.
2.) Return daily until therapeutic.