Response |
Amount (%) (responses/doctors) |
Consensus (> 70%) |
1. What is the initial dose of warfarin for an adult outpatient who has never taken warfarin and whose desirable INR range for therapy is between 2 and 3? |
5 mg/day |
94% (15/16) |
Yes |
2.5 mg/day |
06% (16/01) |
2. And for those patients in poor nutritional status, the elderly, patients with liver disease or those at high risk of bleeding? |
2.5 mg/day |
75% (12/16) |
Yes |
2.0 mg/day |
13% (02/16) |
5 mg/day |
06% (16/01) |
I would not use |
06% (16/01) |
3. Is there any difference in the initial dose of warfarin between inpatients and outpatients? |
No |
75% (12/16) |
Yes |
Yes |
25% (04/16) |
4. After how many days from taking the initial dose should the first INR testing be done to assess the patient? |
5 days |
50% (08/16) |
No |
3 days |
25% (04/16) |
7 days |
25% (04/16) |
5. What should be the frequency of INR monitoring until the desired range is reached? |
weekly |
63% (10/16) |
No |
every 2-3 days |
31% (05/16) |
Daily |
06% (16/01) |
6. Is there a preferable period in a day to collect blood for INR testing? |
Yes, morning. |
56% (09/16) |
No |
No |
44% (07/16) |
7. What should be the frequency for monitoring of INR after reaching the therapeutic range? |
monthly |
81% (13/16) |
Yes |
every 6 weeks |
13% (02/16) |
weekly |
06% (16/01) |
8. When should dose adjustment be done? |
If INR is out of the therapeutic range, after 4-6 days from the beginning of therapy. |
75% (12/16) |
Yes |
If INR is out of the therapeutic range, in two consecutive measurements; |
44% (07/16) |
If after 3 days using warfarin, the patient has not yet reached the expected INR range |
06% (16/01) |
9. Which INR ranges would determine an action for changing the dose? |
INR ≤ 1.5/1.5 < INR ≤ 1.8/ 1.9 ≤ INR < 3.2/ 3.2 ≤ INR < 5.0/INR ≥ 5.0 |
25% (04/16) |
Yes |
1.0 ≤ INR <2.0/ 3.0 < INR < 6.0/ 6.0 ≤ INR < 10.0/ 10.0 ≤ INR ≤ 18.0/ INR > 18.0 |
69% (11/16) |
INR ≤ 1.5/1.51 ≤ INR ≤1.99/ 2.0 ≤ INR ≤ 3.0/ 3.01 ≤ INR < 3.99/ 4.0 ≤ INR ≤ 4.99/5.0 ≤ INR ≤ 8.99/ INR ≥ 9.0 |
13% (02/16) |
other |
25% (04/16) |
No answer |
13% (02/16) |
Questions 10 to 16 refer to an outpatient whose therapeutic INR range is between 2 and 3, and in none of the cases the patient has shown evidence of hemorrhage. |
10. If a patient shows an INR lower than or equal to 1.5; what would the dose adjustment be? |
Increase 20% |
38% (06/16) |
No |
Increase 33% |
31% (05/16) |
Double the dose |
06% (16/01) |
other |
25% (04/16) |
10a. After how many days would you reassess patient status? |
5-7 days |
100% (16/16) |
Yes |
11. What if 1.5 ≤ INR ≤ 1.8? |
Increase 15% |
38% (06/16) |
No |
Increase 10% |
31% (05/16) |
Recollect after a week |
06% (16/01) |
Other |
25% (04/16) |
11a. After how many days would you reassess patient status? |
5 to 7 days |
88% (14/16) |
Yes |
14 days |
13% (02/16) |
12. What if 1.8 ≤ INR ≤ 3.2? |
Do not change the dose |
81% (13/16) |
Yes |
Reduce the dose by 25% |
13% (02/16) |
12a. After how many days would you reassess patient status? |
7-10 days |
44% (07/16) |
No |
30 days |
44% (07/16) |
other |
13% (02/16) |
13. What if 3.2 ≤ INR <4.9? |
Discontinue the next dose and reintroduce warfarin at a weekly dose reduced by 10 -20%. |
50% (08/16) |
No |
Discontinue the next dose and reintroduce warfarin at a weekly dose reduced by 33%. |
44% (07/16) |
Discontinue for three days and reintroduce warfarin at a dose reduced by 25-50%. |
06% (16/01) |
13a. After how many days would you reassess patient status? |
5-7 Days |
88% (14/16) |
Yes |
2-5 days |
06% (16/01) |
14 days |
06% (16/01) |
14. What if 5.0 ≤ INR <9.0, with no evidence of bleeding |
Discontinue warfarin and assess the need to give vitamin K orally (2-4 mg). After 24 hours, if there is no more risk of bleeding, reintroduce warfarin with reduction of 15% in the weekly dose. |
38% (6/16) |
No |
Discontinue the next three doses and then restart the treatment at a dose 33% lower |
38% (6/16) |
Discontinue the next dose and then restart the treatment at lower doses until reach the therapeutic INR |
06% (16/01) |
Discontinue until desirable INR and reintroduce at reduced dose |
06% (16/01) |
Discontinue until desirable INR, reassess in 2-3 days, and reintroduce at reduced dose |
06% (16/01) |
Discontinue warfarin and assess the need to give vitamin K orally (2-4 mg). After 24 hours, if there is no more risk of bleeding, reintroduce warfarin with reduction of 50% in the weekly dose. |
06% (16/01) |
14a. After how many days would you reassess patient status? |
3-7 days |
56% (9/16) |
No |
2 days |
25% (04/16) |
24 hours |
13% (02/16) |
No answer |
06% (16/01) |
15. And if INR > 10.0, with no evidence of bleeding? |
Discontinue warfarin until INR reduction and give 5 to 10 mg of vitamin K orally. |
75% (12/16) |
Yes |
Other |
31% (05/16) |
15a. After how long would you reassess patient status? |
24 hours |
69% (11/16) |
No |
Every 2 Days |
31% (05/16) |
16. In case there is evidence of minor bleeding, what is the dose of vitamin K? |
Discontinue warfarin, give vitamin K 10mg and, if necessary, supplement with fresh plasma or prothrombin concentrate. |
94% (15/16) |
Yes |
Discontinue warfarin, give vitamin K, and restart later |
06% (16/01) |
16a. After how many days would you reassess patient status? |
12 hours |
75% (12/16) |
Yes |
24 hours |
25% (04/16) |
The question below refers to the case of a patient showing evidences of major bleeding: |
17. Sugiro: How would you manage warfarin therapy? |
Discontinue warfarin, give prothrombin complex and vitamin K 10mg 75% (12/16) |
|
Yes |
other |
25% (04/16) |
17a. After how long should the patient be reassessed? |
12 hours |
81% (13/16) |
Yes |
1 day |
19% (3/16) |
The question below refers to the case of a patient experiencing life-threatening bleeding: 18. Sugiro: How would you manage warfarin therapy? |
Discontinue warfarin, give prothrombin complex and vitamin K 10mg |
75% (12/16) |
Yes |
Other |
25% (04/16) |
18a. After how many days would you reassess patient status? |
12 hours |
81% (13/16) |
Yes |
1 day |
19% (3/16) |
Questions |
Second Round |
Response |
Amount (%) (responses/doctors) |
Consensus (> 70%) |
1. How many days after taking the initial dose should the first INR testing be done to assess the patient? |
3 days |
27% (3/11) |
No |
5 days |
55% (6/11) |
1 week |
18% (2/11) |
2. What should be the frequency of INR monitoring until the desired range is reached? |
Every 2-3 days |
36% (4/11) |
No |
Weekly |
64% (7/11) |
3. Is there a preferable period within the day to collect blood for INR testing? |
Yes, morning |
36% (4/11) |
No |
No |
64% (7/11) |
4. When should dose adjustment be done (tick all possible alternatives)? |
If the INR is out of therapeutic range after 4-6 days from the beginning of the therapy. |
100% (11/11) |
Yes |
The following questions refer to an outpatient whose therapeutic INR range is between 2 and 3, and in none of the cases the patient shows evidence of hemorrhage. |
5. If a patient shows INR lower than 1.5, which would be the dose adjustment? |
Increase by 20% |
27% (3/11) |
No |
Double the daily dose |
9% (1/11) |
Increase by 33% |
55% (6/11) |
Other |
9% (1/11) |
6. What if 1.5 ≤ INR ≤1,8 |
Increase by 15% |
64% (7/11) |
No |
Increase by 25% |
36% (4/11) |
7. After how many days would you reassess the status of a patient showing 1.9 ≤ INR ≤ 3.4? |
7-14 days |
73% (8/11) |
Yes |
30 days |
27% (3/11) |
8. What if 3.4 ≤ INR ≤ 5.0 |
Suspend the next dose and reintroduce warfarin with a weekly dose reduced by 10-20% |
55% (6/11) |
No |
Suspend the next dose and reintroduce warfarin with a weekly dose reduced by 33% |
45% (5/11) |
9. What if 5.0 ≤ INR ≤ 9.0 with patient under risk to develop hemorrhage in the next 30 days? |
Discontinue treatment for the 3 next doses and then restart therapy at a dose 33% lower |
45% (5/11) |
No |
Discontinue warfarin treatment and assess the need for oral administration of vitamin K (2-4 mg). After 24 hours, if there is no more risk of bleeding, reintroduce warfarin with 15% reduction |
45% (5/11) |
Other |
9% (1/11) |
9a. After how many days would you reassess patient status? |
24h |
55% (6/11) |
No |
2 days |
9% (1/11) |
3-7 days |
36% (4/11) |
10. What if 9.0 ≤ INR ≤ 20.0? |
Discontinue warfarin therapy until reduction of INR. Reintroduce therapy at low-dose of warfarin and restart dose titration. If required, give vitamin K (5-10mg) |
73% (8/11) |
Yes |
Other |
27% (3/11) |
10a. After how many days would you reassess patient status? |
Daily |
64% (7/11) |
No |
Every 2 Days |
36% (4/11) |
Questions |
Third Round |
Response |
Amount (%) (responses/doctors) |
Consensus (> 70%) |
1. Is there a preferable period during the day to collect blood for INR testing? |
Yes, morning |
50% (4/8) |
No |
No, but always in the same period |
50% (4/8) |
Questions 2 to 5 refer to an outpatient whose therapeutic INR range is between 2 and 3, and in none of the cases the patient shows evidence of hemorrhage. |
2. If a patient shows INR lower than 1.5, which would be the dose adjustment? |
Increase by 20% |
38% (3/8) |
No |
Increase by 33% |
62% (5/8) |
3. What if 1.5 ≤ INR ≤1.8 |
Increase by 15% |
38% (3/8) |
No |
Increase by 25% |
50% (4/8) |
Other |
12% (1/8) |
4. What if 3.2 ≤ INR ≤ 4.9 |
Suspend the next dose and reintroduce warfarin with a weekly dose reduced by 10-20% |
62% (5/8) |
No |
Suspend the next dose and reintroduce warfarin with a weekly dose reduced by 33% |
25% (2/8) |
Other |
12% (1/8) |
5. What if 5.0 ≤ INR ≤ 9.0 with no evidences of bleeding? |
Discontinue the next 3 doses and then restart the therapy at a dose 33% lower |
50% (4/8) |
No |
Discontinue warfarin treatment and assess the need for oral administration of vitamin K (1-2 mg). After 24 hours, if there is no more risk of bleeding, reintroduce warfarin with 15% reduction |
38% (3/8) |
Other |
12% (1/8) |
6. In case there is evidence of bleeding, classified as minor, what should the management be? |
Suspend the next dose, give vitamin K according to INR (1-2 mg for INR> 4.5; p 1-2,5mg/5.0 <INR <9.0; 2,5-5,0mg for INR> = 9.0), monitor, and repeat if necessary, the dose of vitamin K, and restart warfarin therapy |
50% (4/8) |
No |
Discontinue and give vitamin K 1-2 mg, monitor, and repeat if necessary vitamin K, and restart therapy |
38% (3/8) |
Other |
12% (1/8) |
7. In case there is evidence of bleeding, classified as minor, what should the management be? |
Discontinue, give 5-10mg of vitamin K by slow intravenous infusion plus 25-50U/kg of prothrombin complex concentrate or 15ml/kg of fresh plasma, and reassess |
100% (8/8) |
Yes |
8. In case there is evidence of a life-threatening bleeding, what should the management be? |
Discontinue, give 10mg of vitamin K by slow intravenous infusion and 25-50U/kg of prothrombin complex concentrate OR 150 to 300 ml of fresh plasma, and reassess |
75% (6/8) |
Yes |
Discontinue, give 10mg of vitamin K by slow intravenous infusion, 25-50U/kg of prothrombin complex concentrate and 15ml/kg of fresh plasma, and reassess |
25% (2/8) |