I have a pediatric patient (8Kg) currently on 9mg of warfarinfor a prosthetic valve in mitral position. She has an INR of 1.3
The accuracy of preparation and administration of medication has been thoroughly checked. She is not on Vit K supplements. She has no malabsorption or other related concerns. She has not been tested for warfarin-resistance polymorphism, VKORC1 Asp36Tyr as this is not easily available. IV warfarin is no longer available in the US and hence cannot test oral absorption related problems with an IV administration.
My questions are:
1. Would you use as high a dose as it takes to get the INR in the therapeutic range?
2. Is there a side effect unrelated to coagulation that you would be concerned about ?
3. Would any one have similar patient in pediatric age group to do a focused evaluation to understand warfarin resistance?
I don't know similar case. This is atypical case May be you could change warfarin for other anticoagulant
There are no other available effective/proven oral anticoagulants for prosthetic mitral valves. Warfarin resistance is well established. There are established cases in adults who required 145 mg/day to maintain a therapeutic prothrombin time (MacLaren R, Wachsman BA, Swift DK, Kuhl DA. Warfarin resistance associated with intravenous lipid administration: discussion of propofol and review of the literature. Pharmacotherapy 1997; 17:1331–1337) I am looking for pediatric experience and discussion.
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