From Lexi-Comp
To maintain INR 2-3:
Loading:
Day 1: 0.2 mg/kg/day (0.1 mg/kg/day if liver dysfunction is present)
Day 2-4: Depends on daily INR
1.1 - 1.3 → Repeat same dose
1.4 - 3.0 → 50% of loading dose
3.1 - 3.5 → 25% of loading dose
> 3.5 → Hold until INR < 3.5. Then, start 50% of loading dose.
Maintenance (Day 5 & beyond): Depends on INR
1.1 -1.4 → Increase 20%
1.5 - 1.9 → Increase 10%
2-3 → No change
3.1 - 3.5 → Decrease 10%
> 3.5 → Hold until INR < 3.5. Then, start 20% lower than prior dose
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