Considerations for warfarin use in palliative care

Warfarin can become increasingly difficult to manage in advanced illness. Patients often have unstable international normalised ratio (INR) measurements because of poor nutritional status, variable oral intake and drug absorption, liver impairment and drug interactions. Additionally, patients may not be able to take their tablets reliably or have the frequent blood tests required, making it difficult to monitor their INR and adjust the dose effectively.

In patients with palliative care needs, consider switching warfarin to a direct-acting oral anticoagulant (DOAC) or LMWH, unless there is a specific indication for warfarin therapy (eg mechanical valve replacement or VTE associated with antiphospholipid syndrome). For patients with a specific indication, seek specialist advice.