Warfarin Age Adjusted Dosing in Adults HNELHD CG 12_04

Clinical Guideline
Warfarin Age Adjusted Dosing in Adults
Document Registration Number: HNELHD CG 12_04
Sites where Guideline applies This Guideline applies to: 1. Adults 2. Children up to 16 years 3. Neonates less than 29 days Target audience Description Keywords Replaces Existing Guideline? Registration Numbers of Superseded Documents Yes No No Registered Medical Officers Procedure for initial dosing of warfarin according to patients age and dose adjustment according to INR warfarin, INR, anticoagulant Yes Warfarin Age-adjusted Dosing GNAH_0144 from March 2009 All HNE Health Facilities

Related documents (Policies, Australian Standards, Codes of Conduct, legislation etc) NSW Health Safety Notice SN:006/07 Warfarin (revised) (12 April 2007) http://internal.health.nsw.gov.au/quality/sabs/pdf/sn20070412.pdf HNE QUMC Communiqu Independent Check http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0003/81453/Independent_Check_communiq ue_Jan_2011.pdf HNE Policy Compliance Procedure PD2009_077:PCP9 Medicines requiring a double check when administered to Adults http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0003/76746/PD2009_077_PCP_9_V4_Doubl e_Checking_of_Medications.pdf HNE QUMC Communiqu High Risk Medicines http://intranet.hne.health.nsw.gov.au/__data/assets/pdf_file/0005/85406/HNE_AQUM_High_Risk_Medici nes_communique.pdf National Inpatient Medication Chart User Guide (including paediatric versions) January 2011 http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/4DA7912710DA1FBBCA257 78A00151C1E/$File/NIMC%20User%20Guide.pdf Professor Ian Whyte, Chair, HNE Quality Use of Medicines Committee Professor Ian Whyte, Chair, HNE Quality Use of Medicines Committee Ian.whyte@newcastle.edu.au 4921 1283 13 December 2011 HNE Quality Use of Medicines Committee Yes 19 January 2012 1 December 2014 12/28-3-4

Position responsible for Guideline Governance Guideline Contact Officer Contact Details Date authorised Authorising body This Guideline contains advice on therapeutics Issue Date Date for review TRIM number

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Warfarin Age Adjusted Dosing in Adults HNELHD CG 12_04

Prerequisites: Summary:

Initiation of warfarin and subsequent dosing adjustments according to INR must be undertaken by a medical officer This Guideline sets out the steps to be followed when commencing and adjusting the dose of warfarin. The procedural components of the document such as, Preparation of patient, Preparation of equipment, Technique, Cleaning up and Documentation are considered mandatory. This document reflects what is currently regarded as safe and appropriate practice. However in any clinical situation there may be many factors that cannot be covered by a single document and therefore does not replace the need for the application of clinical judgment in respect to each individual patient.

Guideline Note :

OUTCOMES 1 2 Safe and appropriate initiation and dose adjustment of warfarin Provide guidelines for age appropriate commencement doses of warfarin and adjustment according to INR.

GLOSSARY List of abbreviations, acronyms and terms with their definitions Acronym or Term Baseline INR INR IV mg NIMC PO Vitamin K Definition INR taken on day 1 prior to commencement of warfarin sodium International Normalised Ratio Intravenously milligram National Inpatient Medication Chart orally phytomenadione

BACKGROUND In 1999, investigators from Adelaide published a comparison between a warfarin loading protocol adjusting doses for age with an existing protocol (Fennerty's protocol) and empirical dosing1. Patients using the age-adjusted protocol achieved a stable, therapeutic International Normalised Ratio (INR) more rapidly than either of the other groups. The age-adjusted group also had a lower proportion of patients experiencing an INR > or = 4 in the first week as well as a lower proportion having doses withheld in the first week. A modified version, taking into account further risk factors was published in 2003. When trialled, this protocol resulted in most patients rapidly achieving a stable INR with minimal over anticoagulation (63% of patients attained a stable INR after 4 days and 86% after a further two days treatment)2. The protocol coped with other variables shown to affect maintenance warfarin dosing such as weight, gender, pharmacological factors affecting clearance and the presence of designated risk factors3. The early recognition of warfarin sensitivity (via daily INRs for 5 days) is considered to be the absolute key to warfarin initiation and more important than the choice of dose.

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Warfarin Age Adjusted Dosing in Adults HNELHD CG 12_04

GUIDELINE Drug and Presentation:

warfarin sodium 1 mg, 2 mg and 5 mg (Coumadin ) tablets warfarin sodium 1 mg, 3 mg and 5 mg (Marevan ) tablets. Notes: The two (2) available brands of warfarin sodium are not considered bioequivalent and therefore cannot be substituted. Coumadin brand is routinely stocked by HNE facilities.

Ongoing Monitoring: INR should be measured daily in the morning so that drug administration can occur at 4 pm. Warfarin sodium doses on days 2 4 are based on an INR measured 16 18 hours after the previous days dose. Dose: According to age as shown in the table below: warfarin dose
Day INR Age up to 50 yrs

warfarin dose
Age 51-65 yrs

warfarin dose
Age 66-80 yrs

warfarin dose
Age >80yrs

1 2 3

<1.4 <1.6 1.6 <1.8 1.8 - 2.3 2.4 - 2.7 2.8 - 3.1 3.2 - 3.3 3.4 3.5 3.6 - 4.0 >4.0 <1.6 1.6 1.7 - 1.8 1.9 2.0 - 2.6 2.7 - 3.0 3.1 - 3.5 3.6 - 4.0 4.1 - 4.5

4.6 - 5.0 >5.0

10mg 9mg 7.5mg 6mg 10mg 9mg 7.5mg 6mg 0.5mg 0.5mg 0.5mg 0.5mg 10mg 9mg 7.5mg 6mg 5mg 4.5mg 4mg 3mg 4mg 3.5mg 3mg 2mg 3mg 2.5mg 2mg 1mg 2mg 2mg 1.5mg 1mg 1.5mg 1.5mg 1mg 1mg 1mg 1mg 1mg 0.5mg 0.5mg 0.5mg 0.5mg 0.5mg Omit dose Omit dose Omit dose Omit dose 10mg -15mg 9mg -14mg 7.5mg -11mg 6mg -9mg 8mg 7mg 6mg 5mg 7mg 6mg 5mg 4mg 6mg 5mg 4.5mg 3.5mg 5mg 4.5mg 4mg 3mg 4mg 3.5mg 3mg 2.5mg 3.5mg 3mg 2.5mg 2mg 3mg 2.5mg 2mg 1.5mg Omit next days Omit next days Omit next days Omit next days dose then dose then dose then dose then 1mg-2mg 0.5mg- 1.5mg 0.5mg- 1.5mg 0.5mg- 1mg Omit dose and review management with caring physician or surgeon Omit dose & consider need for 0.5mg 1mg of vitamin K (PO or IV)

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PROCEDURES Patient Preparation Patients should be screened for co-existing diseases or conditions such as hepatic impairment, hypo/hyperthyroidism, congestive heart failure, renal impairment, hypoalbuminaemia and high vitamin K intake plus recent trauma, surgery or bleeding problems. Baseline INR: The day 1 INR reflects pre-warfarin baseline.
2

If baseline INR 1.4, reasons for coagulopathy should be assessed . Patients with low albumin may be particularly sensitive to the anticoagulant effects of warfarin. Staff Preparation It is mandatory for staff to follow relevant: Five moments of hand hygiene, infection control, moving safely or safe manual handling, and documentation practices. Medical staff should be familiar with the use of warfarin sodium and its indications and precautions. Clinical staff must use the specific section for ordering warfarin sodium on the National Inpatient Medication Chart (NIMC). Patient counselling including the provision of written information should occur and be documented in the Warfarin Education Record section of the NIMC. Prescribing and Administration To facilitate dosing decisions the INR target range and INR results are to be recorded on the NIMC. The required dose should be prescribed following review of morning INR results. This is best completed by medical staff familiar with the patients medication management. Administer required dose at 4 pm. For patients with active thrombosis continued co-administration of heparin or LMWH should occur until: - warfarin sodium has been administered for a minimum of 4 days, and - the INR reaches a therapeutic level for 2 consecutive days. Additional notes: Warfarin sodium is an anticoagulant and considered a high risk medicine. The two (2) available brands of warfarin sodium are not considered bioequivalent. DO NOT substitute one brand for the other. Refer to the following NSW Health Safety Notice for additional advice or information: - NSW Health Safety Notice SN:006/07 Warfarin (revised) (12 April 2007) http://internal.health.nsw.gov.au/quality/sabs/pdf/sn20070412.pdf

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Warfarin Age Adjusted Dosing in Adults HNELHD CG 12_04 IMPLEMENTATION PLAN CG to be communicated across HNE Health via clinical networks, Area QUM Committee and other communication sources e.g. The Latest, Quality Matters and HNE Health website. EVALUATION PLAN IIMS monitoring of adverse outcomes CONSULATION WITH KEY STAKEHOLDERS Haematology Department HAPS/CMH Area Quality Use of Medicines Committee endorsed 2011 REFERENCES 1. Roberts GW, Druskeit T, Jorgensen LE, Wing LM, Gallus AS, Miller C, Cosh D, Eaton VS. Comparison of an age adjusted warfarin loading protocol with empirical dosing and Fennerty's protocol. Aust N Z J Med. 1999 Oct;29(5):731-6 2. Roberts GW, Helboe T, Nielsen CB, Gallus AS, Jensen I, Cosh DG, Eaton VS. Assessment of an ageadjusted warfarin initiation protocol. Ann Pharmacother. 2003 Jun;37(6):799-803 3. Baker RI, Coughlin PB, Gallus AS, Harper PL, Salem HH, Wood EM, et al. Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis. Medical Journal of Australia 2004;181(9):492-7

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