Warfarin maintenance dosing nomogram

Guidelines for warfarin maintenance dosing adjustments

For Goal INR 2-3              Dosing Adjustments For Goal INR 2.5-3.5                
INR < 1.5
  • consider a booster dose of 1 ½ -2 times daily maintenance dose
  • consider resumption of prior maintenance dose if factor causing decreased INR is transient [eg: missed warfarin dose(s)]
  • if adosage adjustment is needed, increase maintenance dose by 10%–20%
INR < 2.0
INR 1.5-1.7
  • consider a booster dose of 1 ½ – 2 times daily maintenance dose
  • consider resumption of prior maintenance dose if factor causing decreased INR is considered [eg: missed warfarin dose(s)]
  • if a dosage adjustment is needed, increase maintenance dose by 5-15%
INR 2.0–2.3
INR 1.8–1.9
  • no dosage adjustment may be necessary if the last two INRs were in range, if there is no clear explanation for the INR to be out of range, and if in the judgment of the clinician, the INR does not represent an increased risk of thromboembolism for the patient
  • consider a booster dose of 1 ½ – 2 times daily maintenance dose
  • consider resumption of prior maintenance dose if factor causing decreased INR is transient [eg: missed warfarin dose(s)]
  • if a dosage adjustment is needed, increase maintenance dose by 5%–10%
INR 2.3–2.4
2.0-3.0 Desired range 2.5-3.5
3.1-3.2
  • no dosage adjustment may be necessary if the last two INRs were in range, if there is no clear explanation for the INR to be out of range, and if in the judgment of the clinician, the INR does not represent an increased risk of hemorrhage for the patient
  • consider continuation of prior maintenance dose if factor causing elevated INR is transient [eg: acute alcohol ingestion]
  • if a dosage adjustment is needed, decrease maintenance dose by 5%–10%
3.6-3.7
3.3-3.4
  • consider holding ½ to 1 dose
  • consider resumption of prior maintenance dose if factor causing elevated INR is transient [eg: acute alcohol ingestion]
  • if a dosage adjustment is needed, decrease maintenance dose by 5%–10%
3.8-3.9
3.5-3.9
  • consider holding 1 dose
  • Consider resumption of prior maintenance dose if factor causing elevated INR is transient [eg: acute alcohol ingestion]
  • if a dosage adjustment is needed, decrease maintenance dose by 5%–15%
4.0-4.4
> 4.0
  • Hold until INR < upper limit of therapeutic range
  • Consider use of minidose oral vitamin K
  • Consider resumption of prior maintenance dose if factor causing elevated INR is transient [eg: acute alcohol ingestion]
  • if a dosage adjustment is needed, decrease maintenance dose by 5%–15%
> 4.5