Michael J. Kovacs, MD, FRCPC; Philip S. Wells, MD, FRCPC, MSc
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Kovacs M., Wells P.; Randomized Trial of Warfarin Nomograms. Ann Intern Med. 2004;140:491-492. doi: 10.7326/0003-4819-140-6-200403160-00030
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Published: Ann Intern Med. 2004;140(6):491-492.
We thank all of the correspondents for the interest in our article, which has initiated a strong and emotional debate. Given the strong shift, however, of treatment of acute thromboembolism to an outpatient setting using low-molecular-weight heparin, it is imperative to have a simple means to achieve therapeutic oral anticoagulation in an efficient, timely, and predictable fashion.
Much press has been given to the fact that the INR may predominantly reflect factor VII levels during initiation of oral anticoagulant therapy, but with concomitant primary therapy (that is, therapy with low-molecular-weight heparin), no clinical consequences have been reported. Perhaps our nomogram should not be employed if concomitant low-molecular-weight heparin therapy is not used, but there are no data to support this. Despite theoretical concerns using Bayesian modelling, we did not experience a greater rate of critically higher INRs in patients treated using the 10-mg nomogram, and there are no data showing that patients with cytochrome 2C9 require lower initiating doses despite requiring lower maintenance doses of warfarin. Speed may kill in automobiles, but no data prove that it kills with warfarin.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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