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Hematology


Answer 3
  1. Administer a LMWH (eg, enoxaparin 1.0 mg/kg twice daily) along with warfarin 5.0 to 7.5 mg daily. There is never an indication for administering a loading dose of warfarin. Whereas a loading dose of warfarin can cause the INR to reach the therapeutic range more quickly, this occurs only because of a more rapid fall in factor VII. In that situation, the patient is not really anticoagulated, although the INR is in the therapeutic range, and there is an unnecessary risk of embolization that can only be eliminated by starting heparin (either low-molecular-weight heparin [LMWH] or unfractionated heparin) concurrently. Use of heparin alone creates immediate anticoagulation, but unless warfarin is started, the patient will likely be on long-term heparin. Whereas using heparin alone creates a minimal risk if LMWH is used, when unfractionated heparin is used, there is a 3% risk of heparin-induced thrombocytopenia with thrombosis (HITT). Therefore, simultaneous use of LMWH and warfarin is the most appropriate management. Using LMWH also eliminates the need for monitoring of the partial thromboplastin time.

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