Table 3

LMWH bridging protocol for high-risk patients

Days before/after LPWarfarinTreatment dose LMWH
5 days beforeDo not take warfarin
4 days beforeDo not take warfarinStart treatment dose LMWH, check INR is below target range if possible
3 days beforeDo not take warfarinGive treatment dose LMWH
2 days beforeDo not take warfarinGive treatment dose LMWH
1 days beforeDo not take warfarinHold LMWH for 24 hours before LP
Day of LPDo not take warfarin
Check INR≤1.4 before procedure
Take LWMH>4 hours after LP
1 day afterRestart warfarin*Continue LMWH
2 days afterGive warfarin*Continue LMWH
3 days afterDose according to INRStop if/when INR is in the patient’s target range
  • *Warfarin can be restarted at the patient’s usual dose or double the usual dose.

  • INR, international normalised ratio; LMWH, low-molecular-weight heparin; LP,  lumbar puncture.