If there is one thing you might guess from this site, is that I like things fast & concise 🏃🏽♂️ . Coumadin (Warfarin) annoys me since it takes it’s own sweet time to reach peak effect, yet widely used despite much faster acting alternatives available – thanks to much a lower cost. Earlier I had indirectly covered via a quiz how Warfarin got it’s name. The discovery of Coumadin is a fascinating read indeed.
What should the starting dose of Coumadin be ? A standard way to initiate Coumadin therapy is usually with 5mg doses . Many studies have compared a 5mg start versus 10mg start on Coumadin dose, such as these studies published in 2003 , 2004, and more recently two retrospective studies in 2009 – this & this . The 2003 study found using the 10-mg Coumadin nomogram resulted in achieving INRs faster by an average of 1.4 days compared to 5mg start. The 2009 retrospective studies showed a10-mg start was safe even in outpatient setting – majority (70-85%) patients started on 10mg achieving therapeutic INRs within 5 days. Overshooting INRs occured in 5-6% people only.
So in non-frail, non-super-elderly, non-malnourished patients with low bleed risks and no prior major bleed histories, I like to start with 10mg Coumadin doses on Day 1 and 2 (with bridging of course if first time ever use for the patient) , check INR on day 3, next use the 10-mg Coumadin Nomogram as a guide for determining the next doses in consultation with a clinical pharmacist. Even if just a day earlier to reach the target INR , I will take it ! Go big or go home 😉
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