There is generally a significant movement in INR on the third or fourth day after starting warfarin, regardless of whether an initiation protocol is adhered to, or a ‘safe’ dose of 5 mg is used. Even purportedly ‘safe’ starting doses of 5 mg represent a large loading dose for a patient who requires a maintenance dose of only 1−2 mg, and can lead to marked over-anticoagulation in a few days if INRs are not monitored.
Warfarin can be safely started in the community setting, but a recognised initiation protocol should be used. 8 Patients more rapidly achieved a stable INR, had fewer results above 4.0 during the initiation phase and fewer doses withheld due to rapidly rising INRs. The age-adjusted protocol was superior to the Fennerty protocol and to empirical prescribing.
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