1. Warfarin pretest
Joshua Steinberg MD

2. Multiple choice …
Q1: 35 y.o. woman c/o heavy menses and feeling weak and dizzy for the last few days. She takes Coumadin 7 mg PO qHS for dx recurrent DVT/PE prevention (INR goal ). Hasn’t had INR for 6 months. Stat INR is 5.8, hct is 26, vitals are hemodynamically stable. What do you do with her Coumadin dose? A) hold dose x 1 day, resume at 10% lower dose B) lower dose by 20% and continue C) hold dose ‘til INR < 3, then resume at 10% lower D) give Vit K 5 mg PO x1, hold Warfarin dose x 1 day, resume at 20% lower dose

3. Multiple choice
Q2: 70 y.o. woman with chronic A-fib takes 2 mg PO qDay, nurse reports lab draw shows INR 1.6. After assessing that pt is compliant, what dose adjustment do you order? A) extra 2 mg now, increase dose to 3 mg qD B) change to 2 mg qD except 2.5 mg qMon & qThu C) change to alternating 2 mg qD and 3 mg qD D) extra 2 mg now, no change daily dose

4. Multiple choice
Q3: you decide that a 43 y.o. man with artificial valve needs his weekly total Coumadin dose (8 mg qDay as two 4 mg tabs) lowered by 10%. Exactly what do you prescribe? Coumadin … A) 2 mg & 5 mg tabs, 1 each qDay B) 5 mg tabs, 1 tab qMWF, 2 tabs qTuThSaSun C) 4 mg & 5 mg tabs, 1 ½ of the 5mg 4x/wk, 2 of the 4-mg 3x/wk D) 5 mg tabs, 1 ½ qDay

5. Multiple choice
Q4: how confident do you feel about the mgmt recommendations you just made for the high stakes issue of proper, safe anticoagulation? A) really uncomfortable B) mildly uncomfortable C) pretty confident D) no worries whatsoever

6. Goals Better patient care Less headaches/worries for you!
More pts in therapeutic range
Fewer too high, too low
Fewer mistakes/miscommunications
Fewer actual bad pt outcomes (bleeds, clots)
Less headaches/worries for you!

7. Method
Adopt a uniform approach to managing warfarin: “Coumadin protocol”
Features:
Uniform predictable approach to any INR value
Accurate record keeping to follow these pts
Any staff member can handle, such as attending or resident or nurse or clinical pharmacist
It all starts with knowing about Warfarin and our mgmt protocol…