Treatment with Warfarin (Coumadin)

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1 Patient Education Treatment with Warfarin (Coumadin) Warfarin (Coumadin) is a medication that is used to treat and prevent blood clots in the legs, lungs, heart, brain, and other parts of the body. What is warfarin? Warfarin sodium (Coumadin ) is a medication that works as an anti-coagulant. Anti means against and coagulant refers to blood clotting. An anticoagulant helps to prevent clots from forming in the blood. Although warfarin is sometimes called a blood-thinner, it works in the liver to decrease the production of natural blood components called clotting factors. Why are you taking warfarin? Your doctor has prescribed warfarin to prevent the formation of harmful clots or to treat an existing blood clot. Blood clots may form in veins, arteries, or even within the chambers of the heart or on heart valves. Blood clots can create blocks in blood vessels and cut off the blood supply to a portion of the body. Rarely, they can break into fragments called emboli, and be swept along by the blood. Emboli from the veins travel through the heart and lodge in the lung, causing a pulmonary embolus. Emboli from the heart or arteries can cause a stroke if they lodge in the brain. Conditions for which warfarin is recommended include: Atrial fibrillation. Stroke. Following a heart attack. Treatment or prevention of DVT (deep vein thrombosis) or PE (pulmonary embolism). Heart valve disease or heart valve replacement.

2 Page 2 Warfarin therapy requires routine blood testing of the prothrombin time/inr to determine your dose. Doses can change often during treatment with warfarin. How does warfarin work? Warfarin partially blocks the ability of your liver to use vitamin K. Vitamin K is needed to make clotting factors that help the blood clot and prevent bleeding. Vitamin K is found naturally in certain foods, such as green vegetables and certain oils. Warfarin reduces the body s ability to make blood clots. It can help stop harmful clots from forming and keeps clots from getting larger, but it does not break up existing clots. How long does it take for warfarin to work? Warfarin begins to reduce blood clotting within 24 hours after taking the first dose. However, the full effect may take 3 to 5 days to occur. During this time, you may need to be treated with injectable heparin or a low molecular weight heparin until the full effect of warfarin has occurred. How much warfarin should you take? The amount of warfarin needed is different for each person. Your body s response to warfarin is monitored by a blood test called the Prothrombin Time (PT) or International Normalized Ratio (INR). Your warfarin dose is adjusted based on the results of this blood test to achieve your goal range for the INR. What are the PT and INR? Prothrombin Time (PT) is measured in seconds and is the time it takes for your blood to form a clot. International Normalized Ratio (INR) is a more consistent way of reporting the PT and is more widely used to monitor warfarin. Your goal INR is based on your indication for warfarin. Most people have an INR of about 1.0 before they take warfarin. After they start warfarin their goal INR range is between 2.0 and 3.0, or may be higher if they are at greater risk of forming clots. In general, if your INR is below your target range (less than 2.0), you are at greater risk of forming clots and if your INR is above your target range (greater than 3.0), you are at greater risk of having bleeding complications.

3 Page 3 When is your blood tested? When you first start taking warfarin, you may need to get your blood tested twice each week. As your results become more consistent and your warfarin dose becomes stable, blood testing is usually once per month. How often your INR is tested will be determined by your doctor or, if you are managed by an anticoagulation clinic, by the clinic pharmacist or nurse. It is very important that you get your blood tested on the date and time that you are instructed. If you are unable to make a scheduled appointment, it is your responsibility to call and reschedule. Close monitoring of your INR is necessary to prevent blood clots and bleeding. Have your blood tested when you are instructed to by your doctor or by the Anticoagulation Clinic. What are the side effects of warfarin? Side effects with warfarin therapy are not common, but bleeding is the most common. Very minor bleeding may occur even when your INR is in your goal range. This may include an increase in small bruises, or slight gum bleeding when brushing your teeth. Rarely, some people experience skin rash or loss of hair when taking warfarin. If you are experiencing something abnormal that you feel may be caused by your warfarin, please contact the anticoagulation clinic. What are the signs of too much warfarin or a high INR? Minor Bleeding Gum bleeding while brushing teeth. Occasional nosebleed. Easy bruising. Prolonged bleeding after minor cuts. Prolonged menstrual bleeding. You might notice any of these symptoms from time to time. If you are unsure whether bleeding is significant, call your doctor or your anticoagulation clinic. It may be necessary to have your INR checked to be sure.

4 Page 4 If your INR is too high, bleeding may occur. Major Bleeding Red or dark brown urine. Red or black, tarry stool. Vomiting or coughing up blood. Severe headache or stomachache. Unexplained bruising. Frequent nose-bleeds, bleeding gums, or unusual bleeding. Any bleeding that is continuous or excessive. If you have a serious fall or if you hit your head. If you experience any of these signs or symptoms, call your doctor or anticoagulation clinic, or come to the hospital emergency department immediately. What are the symptoms of too little warfarin or a low INR? Blood Clotting Sudden weakness in any limb. Numbness or tingling anywhere. Visual changes or loss of sight in either eye. Sudden onset of slurred speech or inability to speak. Dizziness or faintness. New pain, swelling, redness, or heat in an extremity. New shortness of breath or chest pain. All of the above signs and symptoms can be serious. Remember: Call your doctor or anticoagulation clinic or go to the emergency room right away if any of them occur! When should you take warfarin? Warfarin is taken just once each day. It is important to take your warfarin at approximately the same time each day, usually in the evening. If you have trouble remembering to take warfarin in the evening, talk to your doctor or the pharmacist or nurse.

5 Page 5 You may take warfarin with or without food. It should not upset your stomach. You may also take warfarin at the same time as most other medications. A mediset, daily pill box, and/or dosing calendar can help you keep track of doses. What should you do if you miss a dose? Try not to miss doses of warfarin. If you do miss a dose and you remember the same day, you may take your warfarin later than the scheduled time. If it is already the next day, please call your doctor or anticoagulation clinic for further instruction. If you can t reach your doctor or anticoagulation clinic, skip the missed dose and continue your normal dose the next day. Do not double your dose to catch up. Be sure to mark the missed dose on your calendar and report it at your next doctor or anticoagulation clinic visit. Does warfarin interact with any other medicines? Warfarin interacts with many other medications. This includes prescription medications, as well as over-the-counter medicines, herbs, and vitamin supplements. Therefore, it is extremely important that you contact your doctor or anticoagulation clinic whenever you start or stop any medication, herb, or vitamin. Please check in even if the medication was prescribed by another doctor! You may need more frequent INR checks to prevent interaction with warfarin. If your INR is too low, clotting may occur. Call your doctor or the whenever you start or stop any prescription medication, herbal product, or vitamin supplement. Drug interactions with warfarin can cause changes in the IRN that can increase your risk of bleeding or clotting. There are some medications that you should never take with warfarin because they may also decrease the blood s ability to form clots and therefore increase your risk of bleeding. Never take aspirin without first talking to your doctor or anticoagulation clinic. If your doctor has recommended that you take one aspirin daily, your daily dose should not exceed 81 mg. Do not take other products containing aspirin (Excedrin, Alka- Seltzer, Ascription, Bayer, Bufferin, Ecotrin, Empirin, Nyquil, Pepto Bismol). Do not take ibuprofen (Advil, Motrin, Nuprin, Medipren, Excedrin IB, Haltran, Midol 200, Pamprin-IB), naproxen (Aleve, Naprosyn, Anaprox), ketoprofen (Orudis), cimetidine (Tagamet HB), or famotidine (Pepcid AC). If you need a medication for mild pain relief, you can use acetaminophen (Tylenol). Limit your use of acetaminophen to no more than 2 grams per day (6 of the 325 mg tablets or 4 of the 500 mg tablets).

6 Page 6 Notify your doctor or the if you change the amount of alcohol that you usually drink, if there are any changes in your health, or if there are any changes in your lifestyle or activity level. Is it safe to drink alcohol while taking warfarin? Alcoholic beverages, in moderation, are safe while taking warfarin. This means no more than 1 drink per day if you usually drink alcohol, and no more than 1 or 2 drinks on a special occasion (1 drink = 1 beer = 1 glass of wine = 1 cocktail/shot). Drinking in excess of this can elevate your INR significantly and increase your risk of bleeding. Should you limit activities while taking warfarin? Since warfarin increases your risk of bleeding, you should avoid activities that place you at risk of injury. Talk to your doctor or to your anticoagulation clinic pharmacist or nurse about your current activities and whether or not you should continue these while taking warfarin. Physical activities that are usually safe, such as walking, jogging, swimming, and gardening, may be continued. It is important to let your doctor or anticoagulation clinic staff know about any significant changes in activity level as this may also affect your INR. What if you get sick? Acute illness will change your body s response to warfarin. An episode of congestive heart failure, fever, flu, viral/bacterial infection, nausea, vomiting, or diarrhea can cause your INR to go up and increase your risk of bleeding. If you experience any of the above, please contact your doctor or anticoagulation clinic. Please remember to call before starting an antibiotic. How does diet affect warfarin? Foods that are high in vitamin K may counteract the effect of warfarin and decrease your INR. Foods that are high in vitamin K are usually leafy green vegetables such as spinach and broccoli. The tables on the next page explain which foods have a high vitamin K content. Usually, you should not eat more than one serving per day of food that is high in vitamin K. However, if you consume more than this on a daily basis, your warfarin dose can be adjusted based on your usual dietary intake. The most important thing to remember about your diet is to be as consistent as possible and not to binge on foods that are high in vitamin K. If you are planning on changing your diet temporarily or permanently, call the Anticoagulation Clinic so that your INR can be monitored more closely.

7 Page 7 Key for Levels of Vitamin K: L = low M = moderate H = high BEVERAGES GRAINS Coffee L Bagel L Cola L Cereal L Juices L Flour L Milk L Oatmeal L Tea (black, herbal) L Pasta L Changes in dietary intake of vitamin K containing foods can change your warfarin therapy. Keep your diet consistent and tell your doctor or the Anticoagulation clinic if you change your diet. Tea (green) H Rice L DAIRY PRODUCTS FATS/DRESSINGS Butter L Margarine 7 Tbs M Cheese L Mayonnaise 7 Tbs H Eggs L Oils (canola, salad and soybean) 7 Tbs H Sour cream L Oils (olive) 7 Tbs M Yogurt L Oils (corn, peanut, safflower, sesame, and sunflower) 7 Tbs L FRUITS MEAT AND FISH Apple L Beef L Banana L Chicken L Blueberries L Fish L Canteloupe L Pork L Grapes L Shrimp L Lemon L Tuna L Orange L Turkey L Peach L

8 Page 8 VEGETABLES Asparagus 7 spears M Avocado 1 small M Beans, green ¾ cup L Broccoli ½ cup H Brussels Sprouts 5 sprouts H Cabbage 1½ cups H Cabbage (red) 1½ cups M Carrot ⅔ cup L Cauliflower 1 cup L Celery 2½ stalks L Chard ½ cup H Chive raw ½ cup H Collard greens ½ cup H Corn ⅔ cup L Cucumber (peel removed) 1 cup L Eggplant 1¼ cups L Endive 2 cups H Green pepper (raw) 2 cups L Kale ¾ cup H Lettuce (bib, red leaf) 1¾ cups H Lettuce (iceberg) 5 cups M Mushroom 1½ cups L Mustard greens (raw) 1½ cups H Okra ½ cup M Onion L Parsley (chopped) 1½ cups H Peas green (cooked) ⅔ cup M Potato L Pumpkin L Sauerkraut (canned) ½ cup L Scallions ⅔ cup H Spinach (raw leaf) 1½ cup H Tomato L Turnip Greens (chopped) 1½ cups H Watercress (raw chopped) 3 cups H

9 Page 9 The most important thing is to keep your diet consistent so that the amount of vitamin K in your diet is consistent. Who should know that you re taking warfarin? It is very important to tell each doctor or health care practitioner you visit, your dentist, and each pharmacy where you have prescriptions filled that you are taking warfarin. It may affect how they will care for you in certain situations. If you are going to be taking warfarin for a long period of time, consider wearing an identification bracelet or necklace that will alert emergency health care providers that you are on warfarin. What about pregnancy? You should not take warfarin if you are pregnant. There are other, safer options for anticoagulation in women who are pregnant. Talk to your doctor, anticoagulation pharmacist or nurse if you are planning on becoming pregnant so that you may be switched to another medication in time to prevent harm to the developing fetus. Important Points to Remember: Take your warfarin exactly as directed, at the same time each day. Look for signs of bleeding or clotting and report them immediately. Notify your doctor or anticoagulation clinic of changes in your dietary vitamin K intake, activity level, or medications (including herbal products, vitamins, and over-the-counter medicines). Call your doctor or anticoagulation clinic if you have a fever, diarrhea, vomiting, or loss of appetite lasting longer than one day. Limit alcohol to 1 to 2 drinks per day. Tell each of your health care providers that you are taking warfarin, carry a wallet card, and consider getting an ID bracelet or necklace. Keep all appointments or call promptly to reschedule. Call with any questions concerning your warfarin therapy!

10 Questions? Call Your questions are important. Call your doctor or health care provider if you have questions or concerns. UWMC Clinic staff are also available to help at any time. : Notes: Box N.E. Pacific St. Seattle, WA University of Washington Medical Center 05/2002 Reprints: Health Online

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