Starting treatment in hospital inpatients

Once the indications for anticoagulation have been confirmed (for example, for suspected deep vein thrombosis do venography or D-dimer measurement), the initial dose of oral anticoagulant depends on a patient's coagulation status, age, clinical situation, and degree of heart failure (if present). In older patients, those with impaired liver function, and those with congestive heart failure oral anticoagulation should be started cautiously and the resulting INR checked often (every three to five days). The dose of warfarin needed to maintain an INR at 2.0-3.0, for example, falls with age and is greater in patients of Indo-Asian or African origin than Europeans. Where possible, take routine blood samples for prothrombin time and activated partial thromboplastin time (APTT), platelet count, and liver function tests before starting treatment. Oral anticoagulation with warfarin should be started on day one, preferably in conjunction with heparin because the initial period of treatment with warfarin may be associated with a procoagulant state caused by a rapid reduction in protein C …