Poor INR Control, a Worried Daughter, and a Pending Colonoscopy

Interpretation: a TTR of 48% is poor - well below the >70% benchmark - and the two INRs above 4.5 represent real bleeding exposure while the INR of 1.6 represents unprotected time. He is simultaneously over- and under-anticoagulated, which is the classic signature of a patient who should be reassessed for a direct oral anticoagulant rather than simply "tried harder" on warfarin.

Response to the daughter: separate the two questions she has merged. The question is not "warfarin versus nothing" - with CHA2DS2-VASc 4, stroke risk without anticoagulation is substantial and disabling stroke risk outweighs bleed risk. The real question is which anticoagulant.

• A single mechanical fall without injury is not, by itself, a reason to stop anticoagulation; the number of falls required to offset stroke prevention benefit is very large.
• Validate her concern and redirect it into action: fall-risk review (vision, footwear, home hazards, sedating medications), and a plan to reduce his labile INRs.
• Use the conversation to build consensus for switching agents rather than to defend warfarin.

Apixaban 5 mg twice daily.

Dose-reduction criteria for apixaban in AF require two of three: age ≥80 years, weight ≤60 kg, serum creatinine ≥1.5 mg/dL. He meets zero - he is 74, weighs 62 kg, and his creatinine is 1.4. A common error is to reduce on the basis of one criterion or on eGFR alone; doing so here would under-anticoagulate him. Full dose is correct, with renal function and weight rechecked annually (more often after acute illness) because a single intervening event can flip him into dose-reduction territory.

Transition: stop warfarin and start apixaban when INR is below 2.0.

Aspirin: stop it. He has no coronary stenting, no recent acute coronary syndrome, and no stated atherosclerotic disease - in that setting, aspirin adds bleeding without a matching benefit alongside anticoagulation. Confirm there is no vascular indication in the record before discontinuing, and document the rationale; patients frequently resist stopping "my heart pill," so frame it as removing a medication that is now doubling his bleed risk.

Confirm $47/month is affordable against his budget before switching; if not, work the assistance channels rather than reverting to a warfarin regimen he is failing.

Coordinate with endoscopy, and plan for the procedure actually performed.

• Before: hold apixaban for 48 hours (skip 2 doses) before the procedure, assuming normal renal function and a screening colonoscopy with low-to-moderate bleeding risk. No heparin bridging - bridging is not indicated for DOACs and increases bleeding.
• Day of: confirm with the endoscopist that the plan accounts for possible polypectomy. If a high-bleeding-risk intervention occurs, restart is delayed.
• After: resume apixaban 24 hours after the procedure if hemostasis is achieved; longer only if the endoscopist documents a high-risk bleed or complex resection.
• Cover the gap: his CHA2DS2-VASc 4 means stroke risk exists during interruption, so keep the hold as short as the procedure allows and give him written instructions - this is exactly where patients self-manage badly.
• Don't forget the rest of the visit: confirm aspirin is stopped before the procedure (some endoscopy units will stop it anyway), and use the pre-procedure contact as the switch point to apixaban so he is not managing two transitions at once.

Document the hold dates, the restart date, and who confirmed hemostasis.