C3.2 R4(c): Clarify a medication order with a prescriber #2

ID: TAS is a 37 yo male (wt = 134 kg) admitted with PE and DVT

  • Currently bridging from IV heparin to warfarin for PE/DVT Treatment
  • Original order was for: warfarin 10mg PO once daily x 3 days

Patient’s labs are as follows:

Aug 31 Sept 1 Sept 2
INR 1.0 1.0 1.8
Warfarin 10mg 10mg

On Sept 2, there was a 0.8 jump in INR. Based on the half-lives of clotting factors, the increase by 0.8 is likely due to the peak effect of 1st 10mg dose. Generally, when there is an increase greater than 0.5, we could consider withholding or decreasing the dose.  If the 3rd 10mg dose is administered, the INR may exceed our therapeutic range of 2-3.

Clarified with the prescriber if she would like to decrease or withhold the dose.

Order written:

  1. Please discontinue previous warfarin order.
  2. Warfarin 2mg PO x 1 dose today – MD to reassess tomorrow.

FYI: Follow up

Sept 3 Sept 4
INR 1.6 1.9 2.2
Warfarin 8mg 8mg